RBJ DWX HMUa X4

Arch Sex Behav (2010) 39:213–215
DOI 10.1007/s10508-009-9549-8
LETTER TO THE EDITOR
(Self-)Abusive Prophecies, Rigorous Science, and Discursive

Templates: Commentary on Malón (2009)
Diederik F. Janssen
Published online: 26 September 2009

Springer Science+Business Media, LLC 2009
In his article entitled ‘‘Onanism and Child Sexual Abuse,’’ outside a dialectic model of controversy.1 An insistence on
Malón (2009) proposes a comparative-historical and con- ‘‘objectivity […] precision, rigor and coherence,’’ accordingly,
structivist reading of two etiological plots, with a prospect of may be mistaking the nature of the beast. What seems to be
identifying the latter in terms of scientific ‘‘fallacy,’’ theoreti- needed is a sociology of science, not a scientific sociology.
cal ‘‘hegemony’’ and ‘‘incoherence,’’ ‘‘invasive’’ properties of Deconstructive and critical approaches to psychopathology
hypotheses, and the reign of ‘‘apocalyptic,’’ ‘‘hysterical,’’ and (e.g., Parker, 2002; Parker, Georgaca, Harper, McLaughlin, &
‘‘irrational’’ views. Malón’s key objection is that the histori- Stowell-Smith, 1995) ideally reach beyond an insistence on
cal trajectories of both plots partake in ‘‘the same errors and scientific rigor; indeed, this line of inquiry seems most produc-
excesses’’ that, ultimately, inform a general ‘‘Western’’ contain- tive if identifying ‘‘clinical consensus’’ as a constitutive force
ment of eroticism. Although contending that we are ‘‘com- within specific discursive constellations (feminist research or
pletely immersed’’ in a ‘‘social hysteria,’’ Malón’s critique the forensic apparatus, for instance) and as it relates to over-
works in the direction of a revisionist etiology that liberates arching theoretical projections, such as ‘‘morality’’ and ‘‘cul-
sexual experience from its tendentious evaluation. ture.’’ Genealogical similarity between Onanism and CSA as
Malón should be congratulated both for engaging in this historical etiologies, as sketched by Malón, may pertain to a
late modern quagmire and for his focus on interpretative prac- general template of biomedical discourse formation, but it does
tices. Interpretative practices, Malón convincingly suggests, not necessarily point to a continuity in semantic function, that is
constitute the core substrate of both Onanism and child sexual to say, in discursive instrumentality. I think this is relevant: if a
abuse (CSA), requiring a situating of both notions in various critique of sexological consensus is to be transformative, it may
programmatic frameworks. Indeed, the fundamental conun- have to read the technologies of representation against the
drum of the age-intimacy nexus in Western psychological semantic contingencies that police the direction of the debate.
theories of trauma, from Freud’s seduction via Ferenczi’s Foucault (2003) at this point has famously proposed an im-
confusion of tongues to Laplanche’s (Lacanian) enigmatic portantly incomplete transition from a ‘‘symbolics of blood’’ to
signifiers, is what a ‘‘sex’’ act can be said to signify. an ‘‘analytics ofsexuality,’’ encoding a (correspondingly incom-
There is reason to pause, however, when facing deconstruc- plete) movement from ‘‘fallen girls’’ to ‘‘abuse survivors,’’ from
tive approaches to science that remain within the domain of ‘‘respectability’’ to ‘‘integrity,’’ from marriage and virginity pol-
scientific ambition, including Malón’s, Money’s, and Rind’s itics to a spuriously genderless victimology. Intimacy violations
(both as cited by Malón) among others. The ‘‘condemnation’’ involving classificatory minors have, moreover, been construed
of Rind’s meta-analytic work on the subject a decade ago, quite variably as a crime against the body, against the person,
chronicled by Malón, warned that whereas CSA in the U.S. against the father, against wider filial interests, and against Nat-
is importantly ‘‘about science,’’ it is at the same time placed ure. Hence, to focus, as Malón, on sexuality as an entitled expe-
rientialrealm(world,area),withinwhichscienceblundersandas
invaded by science’s symbolic arrogance, may require a disre-
garding of important historical discontinuities in what sex acts
D. F. Janssen (&)
Berg & Dalseweg 209/60, Nijmegen 6522 BK, The Netherlands
1
e-mail: [email protected] 106 Congress, 1st Session, H. Con. Res. 107 (agreed July 30, 1999).
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214 Arch Sex Behav (2010) 39:213–215
are allowed to signify. Moreover, Malón’s appeal to discursive clear to interpretative anthropologists: the mere ambition of
psychology implies a commitment to discourse as delimiting teasing apart a causative sex act, from an occasioning signifi-
what can count as viable consensus, and what as an apologist’s cation of it as consequential, may already underestimate the
‘‘cognitive distortions.’’ If Malón’s perspective resonates with constitutive function of validation. A close reading of ‘‘CSA,’’
Foucault’s (2003) in identifying modern sexuality as an exclu- in any case, may have to concentrate on trauma where and as
sionary grammar of domestic sociality, it does so because no it really occurs (we might venture: where its occurrences are
‘‘sexual’’ act can make ‘‘proper’’ sense outside of this normative invested with notions of consequentiality), if it is to elucidate
projection (for an angry critique of this, see Edelman, 2004). But the agency of ‘‘faulted and failing’’ sciences.
this observation requires something else than a diagnosis of bad To conclude, may I suggest Malón’s historical thesis can be
science; it requires an analysis of how science is deployed, ex- delivered to a comparative anthropological approach to sexol-
actly how it relates to ‘‘public’’ sentiment, and why hypotheses ogy as an instance of etiological practice. Outside the circum-
should be deployed the way we find them so ubiquitously de- Atlantic world, we frequently encounter hypotheses contrary
ployed. ‘‘Sexuality’’ cannot be rescued from tendentious sex- to occidental traumatology, hypotheses that project the sex act
ology or from the historically progressive domestication of inti- as a sine qua non, a necessary antecedent, an accelerator, or a
macies: it is co-extensive with these. This may well evaporate secondary benefactor of children’s development. The idea that
much of the critique of any discourse as ‘‘obviously extrinsic to ‘‘coitus causes menarche’’ has been attested prevalent at some
a child’s experiences.’’ point in history among Trukese, Onge Andamanese, Australian
While Malón’s comparative appraisal of historical appear- Aborigines (e.g., Walbiri, Murgnin, Anbarra, Tiwi, possibly
ances is key to the debate, what Malón identifies as a ‘‘forcibly Kukatja), New Guineans (e.g., New Irelanders and Dani), Lep-
orchestrated strategy […] a deliberate confounding’’ would as cha, Chewa, Tahitians, Indonesians (Adjehers, To Bada, Bauzi),
yet only tentatively translate to a political motif underlying all Sandwich Islanders, Bororó, Apinayé, Kayapo, Ramkokamer-
sexual versatilities. Homosexuality, Onanism, and CSA, it has kra, Eastern and Western Timbira, Wari’ (Pakaas Novas), Pau
been proposed, all gravitate onto the domestic family—a pre- d’Arco, Tepoztecans, Alkatcho (Alkatcho Carrier) (British Col-
carious emotional ecology and an incubator of social viability— umbia), Kaska, Azande, Kisangani Wagenia, Nyamwezi, Ye-
encoding a semantic contraction that renders sexuality legible as menites, and was found prevalent in medieval to nineteenth
a moral function and as a privileged, specific, symbolic reper- century Europe and in selected ancient medical treatises. Fur-
toire that forcibly implicates ‘‘the child’’ by excluding it.2 CSA, thermore, coitus was documented as considered to be a pre-
more acutely than Onanism, figures in a contemporary articu- requisite for breast development (i.e., as thelopoetic) among the
lation of that function and repertoire. Illustratively, since the Tanzania Parakuyo, Maasai, Trukese, Tiwi, and Bororó; some
1980s, anthropological debates about incest (between co-resi- Karugu assumed coitus to be secondarily thelopoetic. Pubertal
dent kin) have been reformulated by feminists as a psychiatry development was believed to be necessarily preceded by sexual
of ‘‘CSA’’ (involving minors), and through this reformulation activity among the Arapesh, Hopi, and Ifaluk (New Carolines),
feminist anthropology has sought to recalibrate the clinical as in medieval Europe. Illustratively, mythological references
symptomatology feminist sociologists sought to ‘‘expose’’ in the to ‘‘koitogenic’’ menarche are found in Thailand, India, New
late 1970s. What this implies is that ‘‘childhood,’’ ‘‘sexuality,’’ Britain and Mexico, as among the Mataco, Cubeo, and Tukano.3
and political maturity are interlocking rhetorical vectors that A critical reading of these convergent assumptions will un-
importantly precede ‘‘sexual experience,’’ such that there may doubtedly ‘‘uncover’’ abusive experiences and oppressive sex-
hardly be ‘‘essentially benign or even meaningless’’ experience ologies. Regardless, etiology seems to be an exercise in inscrip-
that can be said to escape the symbolic violence of sexological
consensus. Here is perhaps too deep an ‘‘immersion’’ (of ‘‘child’’ 3
Unpublished data; citation list available from author. Research sug-
in ‘‘society’’) than can be undone by a restoration of scientific gest that CSA is independently and negatively associated with age of
honesty. menarche in industrial western settings (Romans, Martin, Gendall, &
Herbison, 2003; Vigil, Geary, & Byrd-Craven, 2005; Zabin, Emerson, &
What is, in other words, implied is that ‘‘CSA’’ may well be
Rowland, 2005). It is generally hypothesized in current literature that
a contestable discursive template but perhaps more important- CSA events, rather than the institutional and wider societal response to
ly it is an historicizeable, normative proclamation catering to them, is causing the stress associated with protracted development.
culturally and historically specific objectives. If so (and Malón While Zabin et al. take into account household characteristics often
related to CSA, they do not extend these to more overarching machin-
agrees with a cultural-historical reading), hypothetical projec-
eries of signification that increasingly precede and contain CSA as an
tions answer to the cultural efficiency of such a proclamation, ‘‘experience’’ or ‘‘exposure.’’ Consequently their hypothesis seems to
not to falsifiability. Malón suggests we can disentangle CSA’s stand or fall with defining CSA by interviewees’ admittance to ‘‘being
webs of significance—an alluring optimism. But this much is sexually touched’’ before menarche by ‘‘anyone older.’’ Reports (Ed-
gardh, 2000; Vigil et al., 2005) suggest that CSA is correlated with men-
arche age, coital debut age, and reproductive debut age, but unsurpris-
2
Foucault speaks of epistemophilic incest that would, in fact, be consti- ingly no study succeeds in teasing apart abuse, stress, and sexual expe-
tutive of the nuclear family. rience per se.
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Arch Sex Behav (2010) 39:213–215 215
tion, not in deduction. In this sense, it cannot productively be Edgardh, K. (2000). Sexual behavior and early coitarche in a national sam-
criticized as failing empirical standards. Studies that coura- ple of 17 year old Swedish girls. Sexually Transmitted Infections, 76,
98–102.
geously try to defamiliarize the obvious, such as Malón’s, align Foucault, M. (2003). Abnormal: Lectures at the Colle`ge de France,
with the classical anthropological stance; yet, anthropology, 1974–1975. New York: Picador.
as history, has proved itself an archive for opportune and pro- Geertz, C. (1983). Local knowledge: Further essays in interpretive an-
grammatic readings (feminism, gay and lesbian politics, family thropology. New York: Basic Books.
Malón, A. (2009). Onanism and child sexual abuse: A comparative study
values), and has otherwise remained peculiarly silent on the of two hypotheses. Archives of Sexual Behavior, doi:10.1007/
issue. Other than gender equity or sexual rights discourses, the s10508-008-9465-3.
CSA thesis seems to warrant a genuinely radical critique of sex- Parker, I. (2002). Critical discursive psychology. London: Palgrave.
uality/sexology as a regulatory idiom, an idiom that weds do- Parker, I., Georgaca, E., Harper, D., McLaughlin, T., & Stowell-Smith,
M. (1995). Deconstructing psychopathology. London: Sage.
mestic and psychic coherence: for better or worse. This idiom Romans, S. E., Martin, J. M., Gendall, K., & Herbison, G. P. (2003). Age
has never been unscientific—it has rather delivered the order- of menarche: The role of some psychosocial factors. Psychological
ing of intimacies to a specifically successful ‘‘skeletonization Medicine, 33, 933–939.
of fact’’ (Geertz, 1983, p. 170). To contest it is to contest more Vigil, J. M., Geary, D. C., & Byrd-Craven, J. (2005). A life history as-
sessment of early childhood sexual abuse in women. Developmen-
than a scientific scam. tal Psychology, 41, 553–561.
Zabin, L. S., Emerson, M. R., & Rowland, D. L. (2005). Childhood sexual
abuse and early menarche: The direction of their relationship and its
References implications. Journal of Adolescent Health, 36, 393–400.
Edelman, L. (2004). No future: Queer theory and the death drive.

Durham, NC: Duke University Press.
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Arch Sex Behav (2010) 39:216–216
DOI 10.1007/s10508-009-9567-6
LETTER TO THE EDITOR
An Explanation for the Shape of the Human Penis

Edwin A. Bowman
Published online: 23 October 2009

Ó Springer Science+Business Media, LLC 2009
The present form of the human penis, reached over several but vaginal secretions, which are then absorbed by the encom-
million years of evolution, was orchestrated by the vagina of passing foreskin. The mucous membrane of the foreskin ad-
the human female. The multifunctional vagina serves as a birth jacent to the glans is highly absorbent, as evidenced by the
canal, a component of the structural support for the internal increased susceptibility of the uncircumcised male to HIV.
pelvic organs, and as a coital organ. In this last function, it has It has been suggested that there may be a glans protecting
had an evolutionary effect in shaping male sexual anatomy. feature of the foreskin, but it is entirely possible that its pri-
Hominid fossils so far discovered show that the female pelvis mary function is to absorb behavior modifying chemical mes-
evolved to accommodate the increasing size of the brain of the sengers from the female. Numerous studies have shown the
human infant. Larger cranial capacity necessitated a larger birth vaginal mucosa to be secretory. In the primate rear-approach
canal and, as a result of sexual selection, an increase in the size coital position, the corona rubs against the anatomically pos-
of the penis. Compared to that of the other great apes, the human terior wall of the vagina, the most dependent surface when
penis is considerably larger, and evidence suggests that its un- the woman is standing, and therefore the place more likely to
ique configuration may also be a result of vaginal influence. collect vaginal secretions. The deepest end of the posterior
It has been proposed that the shape of the glans with its vagina is the cul de sac, which commonly contains a small
distinctive corona facilitates the scooping out of previously amount of fluid. An analytical study of the vaginal secretions
deposited semen, enabling the subsequent deposition of other of an ovulating female for neuropeptides, such as pitocin and
genetic material. This is not a likely occurrence. The healthy vasopressin, known to enhance pair bonding and protective
vagina has a low pH to protect it from invading organisms. behavior in the male, could be revealing. Sexual intercourse
This intense acidity will kill all sperm not promptly reaching may be a medium of communication between humans older
the safety of the cervical mucus. I suggest the evolutionary than language itself.
function of the glans and its corona is not to scoop out semen
E. A. Bowman (&)
515 Holly Point Road, Freeport, FL 32439, USA
e-mail: [email protected]
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Arch Sex Behav (2010) 39:217–220
DOI 10.1007/s10508-009-9548-9
EDITORIAL
Reports from the DSM-V Work Group on Sexual and Gender

Identity Disorders
Kenneth J. Zucker

American Psychiatric Association 2009
DSM Prolegomena taken in DSM-III with regard to etiology is that the inclu-
sion of etiological theories would be an obstacle to use of
Since the first edition of the Diagnostic and Statistical Manual: the manual by clinicians of varying theoretical orientations,
Mental Disorders was published in 1952 by the American since it would not be possible to present all reasonable
Psychiatric Association (APA), the manual has gone through a etiological theories of each disorder…. Because DSM-III is
series of revisions: DSM-II in 1968, DSM-III in 1980, DSM-III- generally atheoretical with regard to etiology, it attempts to
R in 1987, DSM-IV in 1994, and a text revision to the DSM-IV describe comprehensively what the manifestations of the
in 2000. For those with a sharp eye, one will note that, sub- mental disorders are, and only rarelyattempts to account for
sequent to DSM-I, the manual has had a slightly different name: how the disturbances come about… This approach can be
Diagnostic and Statistical Manual of Mental Disorders. said to be ‘‘descriptive’’ in that the definitions of the dis-
Any clinician, researcher, or policy maker with an interest in orders generally consist of descriptions of the clinical fea-
psychiatric nosology is keenly aware that the publication of the tures of the disorders. (American Psychiatric Association,
DSM-III in 1980 was a watershed moment in contemporary 1980, pp. 6–7)
psychiatry. By that time, the intellectual and institutional hege-
A psychiatric nosology that was, by and large, agnostic with
mony of psychoanalysis that had dominated the psychiatric
regard to underlying causal mechanisms was deemed preferable
landscape had lost some, if not most, of its grip (see Grob, 1991;
to a theoretical model that was no longer satisfying to many
Paris, 2005; Wilson, 1993). Sketchy psychoanalytic models of
researchers and practitioners. Advances in biological psychia-
at least some psychiatric disorders that were described in the
try, the emergence of competing psychologic models of devel-
DSM-I and DSM-II were abandoned. The rather vague diag-
opment and disorder, and the increasing availability of alter-
nostic descriptors were replaced by more detailed criteria and,
native approaches to therapeutics all contributed to a paradigm
for the majority of conditions described in the DSM-III, an
crisis in the discipline’s nosological manual. Since 1980, one
atheoretical approach predominated. As noted in the Introduc-
overarching vision was that the manual, if organized around
tion to the DSM-III:
descriptively neutral diagnostic criteria, could be utilized by a
For most of the DSM-III disorders…the etiology is un- diverse array of clinicians and researchers from many disci-
known…. The approach taken in DSM-III is atheoretical plines. A common and transparent language, so it has been held,
with regard to etiology or pathophysiological process ex- should facilitate communication in a rapidly developing field
cept for those disorders for which this is well established (see Spitzer & Klein, 1978).
and therefore included in the definition of disorder…. The There was also another very crucial issue that served as a
major justification for the generally atheoretical approach backdrop to the substantive changes that occurred with the
publication of DSM-III, namely the concern that the prior
K. J. Zucker (&) manuals lacked sufficient detail to produce reliable and valid
Gender Identity Service, Child, Youth, and Family Program, diagnostic categories. This was already apparent in the 1960s
Centre for Addiction and Mental Health, 250 College St., Toronto, (e.g., Spitzer, Cohen, Fleiss, & Endicott, 1967; Spitzer, Fleiss,
ON M5T 1R8, Canada Burdock, & Hardesty, 1964; Stoller & Geertsma, 1963), but was
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218 Arch Sex Behav (2010) 39:217–220
brought to the fore by the seminal work by a team of psychia- for field trials to test revised diagnostic criteria; and (6) revi-
trists at Washington University in St. Louis (e.g., Feighner et al., sion to the text that accompanies each diagnosis.
1972; Goodwin & Guze, 1979; Robins & Guze, 1970). The In addition, the Task Force will examine some other major
importance of reliability and validity has remained a central issues: (1) the meta-structure of the manual, i.e., disorder group-
concern in all of the post-DSM-III manuals (see, e.g., Blashfield, ings; (2) measurement of distress and impairment; (3) the pos-
Sprock, & Fuller, 1990; Nelson-Gray, 1991; Pincus, Frances, sible inclusion of dimensional diagnosis as a complement to
Davis, First, & Widiger, 1992; Tsaung, 1993; Widiger, Frances, categorical diagnosis; (4) the possible inclusion of common
Pincus, & Davis, 1990; Widiger, Frances, Pincus, Davis, & dimensional assessment that will be used across different diag-
First, 1991) and will continue to do so with the publication of nostic categories; (5) further consideration of developmental
DSM-V. parameters for diagnosis; and (6) further consideration of cul-
For the last 30 years, it would be very reasonable to state the tural factors and gender vis-à-vis diagnosis. For these issues, the
obvious: the DSM has had an enormous (international) impact interested reader can consult the following: Andrews, Charney,
on clinical training, the delivery of clinical care, and programs of Sirovatka, and Reiger (2009), Beach et al. (2006), Dimsdale et al.
research (both basic and applied). It has also served as a spring- (2009), Helzer and Hudziak (2002), Helzer et al. (2008), Hyman
board for continued and considered reflection on the contem- (2007), Kraemer (2007), Krueger, Skodol, Livesley, Shrout, and
porary concept of mental disorder (see, e.g., Decker, 2007; Huang (2007), Kupfer, First, and Regier (2002), Kupfer, Regier,
Fabrega, 1994, 2006, 2007; Horwitz, 2002; Horwitz & Wake- and Kuhl (2008), Narrow, First, Sirovatka, and Regier (2007),
field, 2007; Houts, 2002; Jablensky, 2007; Jensen, Knapp, & Phillips, First, and Pincus (2003), Regier, Narrow, First, and
Mrazek, 2006; Kendell, 2001, 2002; Kendell & Jablensky, Marshall (2002), Regier, Narrow, Kuhl, and Kupfer (2009), and
2003; Kendler, 1999; Lane, 2007; Lewis, 2006; Lilienfeld & Tackett, Balsis, Oltmanns, and Krueger (2009).
Marino, 1995; Luhrmann, 2001; McNally, 2001; Paris, 2008;
Scotti, Morris, McNeil, & Hawkins, 1996; Silk, Nath, Siegel, &
Kendall, 2000; Spitzer, 1999; Spitzer & Endicott, 1978; Wake- The Sexual and Gender Identity Disorders Work Group
field, 1992a, 1992b, 1993, 1997; Widiger & Clark, 2000; Zachar
& Kendler, 2007). At the time of completing this Editorial It was an honor and privilege for me to be appointed as Chair of
(August 30, 2009), the simple search term ‘‘DSM’’ in PubMed this Work Group by the DSM-V Task Force and the American
yielded a mere 28,223 entries! Psychiatric Association. My first task was to consult with the
Task Force regarding candidates for the Work Group. There
was, of course, a restriction on how many members could be
Back to the Future appointed to the Work Group. Vetting nominees is a time-
consuming process. It also costs money, as does participation in
On April 13, 2006, the APA announced the appointments of face-to-face meetings and conference calls. Thus, for our Work
David J. Kupfer, M.D., as chair, and Darrel A. Regier, M.D., Group, as for others, it was impossible to consider all qualified
M.P.H., as vice chair, of the DSM-V Task Force (American candidates. Apart from consideration of scholarly qualifica-
Psychiatric Association, 2006). And on May 1, 2008, the APA tions, it was also important to adhere to the conflict of interest
announced the appointments of the entire ensemble of the guidelines set forth by the Task Force, including a ceiling set on
DSM-V Task Force (American Psychiatric Association, 2008), the amount of personal income received from the pharmaceutical
including the 13 Work Group Chairs for the current groupings of industry (see Cosgrove, Krimsky, Vijayaraghavan, & Schneider,
psychiatric disorders in the DSM-IV, its cross-cutting Work 2006), an issue that was particularly relevant for our Sexual
Groups, other members of the Task Force, and so on. Since then, Dysfunctions subworkgroup. The Work Group that material-
many advisors have been nominated and approved by the Task ized included the following individuals: For the Sexual Dys-
Force to consult with the Work Groups, resulting in an even larger functions subworkgroup, R. Taylor Segraves (Chair), Yitzchak
cast. The anticipated publication of the DSM-V is 2012, five years M. Binik, Lori A. Brotto, and Cynthia Graham; for the Pa-
later than predicted by Blashfield and Fuller (1996). For further raphilias subworkgroup, Ray Blanchard (Chair), Martin P.
information on the DSM-V, the reader is encouraged to consult Kafka, Richard Krueger, and Niklas Långström; for the Gender
www.dsm5.org. Identity Disorders subworkgroup, Peggy T. Cohen-Kettenis
The DSM-V Task Force has, as its mission, a number of (Chair), Jack Drescher, Heino F. L. Meyer-Bahlburg, and
major tasks. These include, but are not limited to, the follow- Friedemann Pfäfflin. Members of each Work Group nominated a
ing: (1) literature reviews of current diagnostic entities; (2) number of advisors, many of whom are acknowledged in the
literature reviews of proposed new diagnostic categories; (3) literature reviews that are part of this Special Section of Archives.
incorporation of feedback from advisors and the scientific In this issue (and already available via advance online pub-
community at large, as well as other interested stakeholders; lication), the reader will find a total of 16 reviews written by our
(4) examination of relevant secondary data sets; (5) proposals Work Group. Reviews by Taylor Segraves on the male sexual
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Arch Sex Behav (2010) 39:217–220 219
dysfunctions will be published in the Journal of Sexual Medi- Blashfield, R. K., Sprock, J., & Fuller, A. K. (1990). Suggested guide-
cine. Most of the reviews focus on a critical appraisal of the lines for including or excluding categories in the DSM-IV.
Comprehensive Psychiatry, 31, 15–19.
relevant diagnoses that appeared in the DSM-IV (or earlier), Cosgrove, L., Krimsky, S., Vijayaraghavan, M., & Schneider, L. (2006).
with proposed suggestions for reform and revision. There is also Financial ties between DSM-IV panel members and the pharma-
one review that considers the addition of a new diagnosis (Hyper- ceutical industry. Psychotherapy and Psychosomatics, 75, 154–160.
sexuality) and two reviews on gender identity disorder con- Decker, H. S. (2007). How Kraepelinian was Kraepelin? How Kraepel-
inian are the neo-Kraepelinians?—from Emil Kraepelin to DSM-III.
sider conceptual and sociopolitical/historical parameters. History of Psychiatry, 18, 337–360.
Each review was subject to internal feedback by the Work Dimsdale, J. E., Xin, Y., Kleinman, A., Patel, V., Narrow, W. E.,
Group and, in some cases, from feedback by advisors. It Sirovatka, P. J., et al. (Eds.). (2009). Somatic presentations of mental
should be made clear that the recommendations and options disorders: Refining the research agenda for DSM-V. Arlington, VA:
American Psychiatric Association.
embedded in these reviews are just that. In no way should the Fabrega, H. (1994). International systems of diagnosis in psychiatry.
reviews be considered the ‘‘final product.’’ The final product Journal of Nervous and Mental Disease, 182, 256–263.
is a multi-layered process that will involve additional feed- Fabrega, H. (2006). Why psychiatric conditions are special: An evolu-
back and certainly will be influenced by the results from field tionary and cross-cultural perspective. Perspectives in Biology and
Medicine, 49, 586–601.
trials. Fabrega, H. (2007). How psychiatric conditions were made. Psychiatry,
Publishing these reviews in the Archives is part of the trans- 70, 130–153.
parency process that is of critical importance to the DSM-V Task Feighner, J. P., Robins, E., Guze, S. B., Woodruff, R. A., Winokur, G., &
Force. It allows interested members of the scientific community Munoz, R. (1972). Diagnostic criteria for use in psychiatric research.
Archives of General Psychiatry, 26, 57–63.
and other stakeholders to scrutinize the thinking of our Work Goodwin, D. W., & Guze, S. B. (1979). Psychiatric diagnosis (2nd ed.).
Group and to provide feedback. In our post-modern era, where a New York: Oxford University Press.
micro-thought is just a twitter away, the scientific periodical is, I Grob, G. N. (1991). Origins of DSM-I: A study in appearance and reality.
hope, still a useful forum for reflection, critique, and dialogue. American Journal of Psychiatry, 148, 421–431.
Helzer, J. E., & Hudziak, J. J. (Eds.). (2002). Defining psychopathology in
Commentaries that are no more than 1500 words in length the 21st century: DSM-V and beyond. Washington, DC: American
will be considered for subsequent publication in the Archives. Psychiatric Publishing.
Commentaries should be submitted to Kenneth J. Zucker, Helzer, J. E., Kraemer, H. C., Krueger, R. F., Wittchen, H.-U., Sirovatka,
Ph.D., Editor, Archives of Sexual Behavior at Ken_Zucker@ P. J., & Regier, D. A. (Eds.). (2008). Dimensional approaches in
diagnostic classification: Refining the research agenda for DSM-
camh.net. The commentary should be submitted as an e-mail V. Arlington, VA: American Psychiatric Association.
attachment using WORD, should contain a brief title, the au- Horwitz, A. V. (2002). Creating mental illness. Chicago: University of
thor’s complete mailing address, and the use of the reference Chicago Press.
style of the American Psychological Association. Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness: How
psychiatry transformed normal sorrow into depressive disorder.
Oxford: Oxford University Press.
Acknowledgment The author is the Chair of the DSM-V Work Group Houts, A. C. (2002). Discovery, invention, and the expansion of the modern
on Sexual and Gender Identity Disorders. Reprinted with permission from Diagnostic and Statistical Manual of Mental Disorders. In L. E.
the Diagnostic and Statistical Manual of Mental Disorders V Workgroup Beutler & M. L. Malik (Eds.), Rethinking the DSM: Psychological
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DOI 10.1007/s10508-009-9543-1
ORIGINAL PAPER
The DSM Diagnostic Criteria for Hypoactive Sexual Desire

Disorder in Women
Lori A. Brotto

Ó American Psychiatric Association 2009
Abstract Hypoactive Sexual Desire Disorder (HSDD) is one women. This review will also discuss criticisms of the existing
of two sexual desire disorders in the Diagnostic and Statistical Diagnostic and Statistical Manual of Mental Disorders (DSM-
Manual of Mental Disorders (DSM) and is defined by the IV-TR; American Psychiatric Association, 2000) criteria and
monosymptomatic criterion ‘‘persistently or recurrently defi- summarize prior attempts to offer alternate diagnostic criteria
cient (or absent) sexual fantasies and desire for sexual activity’’ and taxonomies. The issues to be considered for DSM-V in-
that causes ‘‘marked distress or interpersonal difficulty.’’ This clude: (1) the utility of including lack of sexual fantasies in the
article reviews the diagnosis of HSDD in prior and current criteria; (2) whether or not ‘‘responsive desire’’ should be added
(DSM-IV-TR) editions of the DSM, critiques the existing cri- to the criteria; (3) how to capture relational influences and con-
teria, and proposes criteria for consideration in DSM-V. Prob- sequences; (4) the overlap between sexual desire and sexual
lems in coming to a clear operational definition of desire, the fact arousal/arousability; and (5) whether or not associated distress
that sexual activity often occurs in the absence of desire for should be part of the diagnostic criteria.
women, conceptual issues in understanding untriggered versus It is important to first clarify terminology used. In the profes-
responsivedesire,therelativeinfrequencyofunprovokedsexual sional literature, the terms sexual desire, drive, motivation, inter-
fantasies in women, and the significant overlap between desire est, libido, hunger, and appetite are often used interchange-
and arousal arereviewedand highlight theneed forrevisedDSM ably. In the DSM-IV-TR, whereas the disorder itself and the
criteria for HSDD that accurately reflect women’s experiences. associated criteria focus on sexual ‘‘desire,’’ the ‘‘Associated
The article concludes with the recommendation that desire and Features and Disorders’’ section also uses the term ‘‘sexual in-
arousal be combined into one disorder with polythetic criteria. terest.’’ This review will conclude with one recommendation
that the phrase ‘‘sexual interest’’ replace ‘‘sexual desire.’’
Keywords Hypoactive sexual desire disorder The categories of sexual disorders in the DSM since 1980
Sexual interest Sexual desire DSM-V (DSM-III; American Psychiatric Association, 1980) have been
based on the human sexual response cycle as originally con-
ceptualized by Masters and Johnson (1966). Shortly after the
Introduction release of their book on treatment, Human Sexual Inadequacy
(Masters & Johnson, 1970), it became readily apparent that the
The goal of this review is to provide an overview on the history primary complaint for which patients sought treatment was not
and current status for making a diagnosis of hypoactive sexual problems with sexual performance or genital excitement, as
desire disorder (HSDD). In line with the recommendation by Masters and Johnson had assumed. Instead, problems relating to
Segraves, Balon, and Clayton (2007) that criteria sets be listed a lack of sexual interest were the most common presentations
separately by sex, this article will focus on sexual desire in among women. Today, we would refer to this as a lack of sexual
desire. In the late 1970s, Kaplan (1977, 1979) and Lief (1977)
independently suggested that desire is a necessary separate
L. A. Brotto (&)
phase of the human sexual response cycle and Masters and
Department of Obstetrics and Gynaecology, University of British
Columbia, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada Johnson’s model was expanded to acknowledge the important
e-mail: [email protected] role of sexual desire. The resulting triphasic model emphasized
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Kaplan’s and Lief’s view that sexual desire was the first and methodologies employed—in particular, whether distress was
most important component, which triggered the rest of the assessed and considered in determining prevalence rates. The
sexual response cycle. This triphasic sexual response cycle of National Health and Social Life Survey (NHSLS) is one of the
desire, excitement, and orgasm (and resolution), served as the most widely cited studies on the prevalence of sexual problems
basis for how sexual disorders were categorized in the DSM: in women (Laumann, Paik, & Rosen, 1999). Between 27 and
Sexual Desire Disorders, Sexual Arousal Disorders, and Or- 32% of women aged 18–59 who had been sexually active over
gasm Disorders mapped on to the first three phases of the sexual the past year responded with ‘‘yes’’ to the question: ‘‘During the
response cycle, and the Sexual Pain Disorders were added as a last 12 months has there been a period of several months or
fourth category of dysfunction with no apparent justification for more when you lacked desire for sex?’’ In the National Survey
their addition in either the DSM-III, DSM-III-R, DSM-IV, or of Sexual Attitudes and Lifestyles (NATSAL) conducted on
any of the DSM Sourcebooks. The disorder of low sexual desire 11,161 British men and women aged 16–44 who participated in
in the DSM-III was labeled ‘‘Inhibited Sexual Desire’’ and was a computer-assisted self-interview, low sexual desire was the
defined as a persistent and pervasive inhibition of sexual desire. most common complaint in women (Mercer et al., 2003). The
The DSM-III stipulated that the diagnosis would rarely be made prevalence of low desire ‘‘lasting at least one month’’ was 40.6%
unless the lack of desire was a source of distress to either the and ‘‘lasting at least six months’’ was 10.2%. In the Global Study
individual or a partner. of Sexual Attitudes and Behaviors (GSSAB), 13,882 women
The revised edition of DSM-III (DSM-III-R; American Psy- across 29 countries took part either in a computer-assisted
chiatric Association, 1987) dropped the term ‘‘inhibited’’ because telephone interview or a face-to-face interview (Laumann et al.,
of its assumed psychoanalytic (and potentially ambiguous) con- 2005). Lack of interest in sex was the most common problem in
notation and it was replaced with hypoactive sexual desire dis- women, ranging from 26 to 43%. Distress was not assessed in
order (HSDD). Replacement of the term ‘‘inhibited’’ also allowed these three studies.
for sexual desire disorder to be defined in the same way for men
and women (Graham & Bancroft, 2006). The DSM-III-R defined
HSDD as ‘‘persistently or recurrently deficient or absent sexual Prevalence of Low Sexual Desire and Associated Distress
fantasies and desire for sexual activity.’’ Subtypes (psychogenic
or psychogenic/biogenic; lifelong or acquired; and generalized or Researchers have also attempted to quantify the prevalence
situational) were introduced to further define the HSDD syn- of low sexual desire (DSM-IV-TR Criterion A) versus the
drome. The name and criteria for HSDD remained the same in prevalence of low sexual desire and associated distress (DSM-
DSM-IV except that the criterion of having ‘‘marked distress or IV-TR Criteria A and B).
interpersonal difficulty’’ was added. Thus, the individual with In a Swedish study of 1,335 women aged 18–74, 34% of
deficient (or absent) sexual fantasies and desire for sexual activity women reported that they experienced decreased sexual interest
who was not distressed by these symptoms did not meet criteria quite often or most of the time. Among this group, 43% viewed
for HSDD. the low desire as a problem (Fugl-Meyer & Fugl-Meyer, 1999).
Criterion A for HSDD requires ‘‘persistently or recurrently Bancroft, Loftus, and Long (2003) conducted telephone inter-
deficient (orabsent) sexual fantasiesanddesire forsexual activity’’ views with 987 American women aged 20–65 and examined the
and Criterion B requires that ‘‘the disturbance causes marked prevalence of sexual dysfunction, personal distress, and distress
distress or interpersonal difficulty’’ (American Psychiatric Asso- about the relationship. Women aged 20–35 were more likely to
ciation, 2000). In determining whether the lack of sexual fantasies view their lack of sexual thoughts as distressing to the rela-
or desire for sexual activity are clinically significant, the DSM-IV- tionship and to their own sexuality compared to women aged 36
TR instructs that ‘‘the judgment of deficiency or absence is made and older. The prevalence of low desire in this study was op-
by the clinician, taking into account factors that affect sexual erationalized by asking women the frequency with which they
functioning, such as age and the context of the person’s life.’’ thought about sex with interest or desire over the past month.
Criterion C indicates that the lack of sexual desire is not ‘‘better Response options were: not at all, once or twice, once a week,
accounted for by another Axis I disorder (except another Sexual several times a week, and at least once a day, with 7.2% of the
Dysfunction) and is not due exclusively to the direct physiological women reporting no sexual interest over the past four weeks.
effects of a substance or a general medical condition.’’ Bancroft et al. found that negative mental state was the best
predictor of marked distress about the relationship as well as
marked distress about the woman’s own sexuality (although the
Prevalence of Low Sexual Desire in Women authors recognized that the reverse order of causation was also
feasible but less likely). Moreover, mental state (e.g., feeling
Over the past decade, there have been numerous attempts to calm and peaceful) was more predictive of relational distress
document the prevalence of low desire and HSDD in women. than was physical health, whereas physical health was more rele-
There have been some inconsistencies in the findings and vant to distress about a woman’s own sexuality. Interestingly,
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Arch Sex Behav (2010) 39:221–239 223
perceived impairment in physical genital response was only interviews during which women completed the PFSF and PDS.
marginally predictive of distress about the relationship and did Using a PFSF desire domain cut-off score of 40, the overall
not influence personal distress. prevalence of low desire was 36.2% (20.3% for Black women,
Oberg, Fugl-Meyer, and Fugl-Meyer (2004) analyzed Swe- 38% for non-Hispanic White women, and 39.6% for Hispanic
dish data collected in 1996 and explored mild and manifest low women). Using a PDS cut-off score of 60 together with low
desire (DSM Criterion A) and mild and manifest distress (DSM desire, the overall prevalence of HSDD was 8.3% (3.2% for
Criterion B). Manifest dysfunction was considered when the Black women, 9.2% for non-Hispanic White women, and 9.8%
symptom was experienced quite often, nearly all the time, or all for Hispanic women). Naturally menopausal women had the
the time. Mild dysfunction was considered when the symptom most complaints of low desire (52.4%). Rates of low sexual de-
was experienced hardly ever or quite rarely. In their sample of sire for surgically menopausal and premenopausal women were
1,056 women aged 19–65 who had been sexually active in the 39.7 and 26.7%, respectively. However, rates of HSDD were
past year, 89% reported either mild (60%) or manifest (29%) low lower for all women but highest for surgically menopausal
desire, whereas 59% reported low desire plus the associated women (12.5%) compared to 6.6 and 7.7% for naturally men-
mild (44%) or manifest (15%) distress. Thus, when only manifest opausal and premenopausal women. Young surgically meno-
low desire was considered (i.e., women who reported low desire pausal women had complaints of low desire matching premeno-
quite often, nearly all, or all of the time), 29% experienced this pausal women (26 and 27%), but the highest rates of HSDD,
symptom and, of this group, 47% had manifest distress, 40% had even after controlling for age, race/ethnicity, educational level,
mild distress, and 13% were not distressed. That 13% of the and smoking status using an adjusted prevalence ratio. Older
women with significant symptoms of low desire were not dis- women with bilateral salpingo-oophorectomy (BSO) post-men-
tressed by them is an interesting issue that will be explored further opause also had higher rates of HSDD (15%) while their com-
in this review. plaints of low desire matched those of older women with intact
The Women’s International Study of Health and Sexuality ovaries. These data suggest that it is not menopause, per se, that
(WISHeS) is an industry-funded international study examining negatively influences sexual desire; rather, surgical menopause
sexual function and distress. One publication based on the in the relatively recent past is linked to distress about low desire
WISHeS data focused on 952 mostly White American women (older women with distant BSO had lower prevalence of HSDD,
who completed the Profile of Female Sexual Function (PFSF) 8.5%). These data also suggest that the prevalence of low desire
and the Personal Distress Scale (PDS), two measures developed with distress is significantly lower than the prevalence of low
by Procter and Gamble Pharmaceuticals and not in the public desire alone.
domain. Rates of low desire were 24–36%, depending on age Witting et al. (2008) examined the prevalence of low desire
and menopausal status (Leiblum, Koochaki, Rodenberg, Bar- and associated distress in a population based Finnish sample of
ton, & Rosen, 2006). The rates of low desire with distress ranged 5,463 women aged 18–49 using the Female Sexual Function
from 9% (naturally menopausal women), 14% (premenopausal Index (FSFI; Rosen et al., 2000) and a shortened version of the
women), 14% (older surgically menopausal women), to 26% Female Sexual Distress Scale (FSDS; Derogatis, Rosen, Leib-
(young, surgically menopausal women). International data on lum, Burnett, & Heiman, 2002). Fifty-five percent of the sample
the WISHeS study, with a focus on 2,467 European women experienced low sexual desire (defined as a FSFI desire subscale
aged 20–70, found comparable rates. Low desire ranged from score\3.16 from a possible range of 1.2–6) and 23% experienced
16 to 46%, depending on age and menopausal status (Denner- associated distress (defined as a FSDS score[8.75 from a pos-
stein, Koochaki, Barton, & Graziottin, 2006). However, these sible range of 0–28). The prevalence of low desire was higher
numbers dropped drastically when the prevalence of low desire than that reported by Oberg et al. (2004) and West et al. (2008).
and distress together were considered: 7% of premenopausal The low desire plus distress frequency was similar to the rates in
women, 9% of naturally menopausal women, 12% of surgically Oberg et al. (2004); however, both of these studies showed higher
menopausal older women, and 16% of surgically menopausal rates of low desire plus distress than the study by West et al.
young women. Similar to the findings of Bancroft et al. (2003), (2008). Also similar to the finding by Oberg et al. (2004) was that
this group of European women with HSDD were significantly this study found a prevalence of distress alone (defined by high
more likely to endorse negative emotions or psychological FSDS scores), in the absence of low desire (defined by low FSFI
states than women with normal desire. desire scores), to be 12.4%. It is possible that the much higher rate
In a more recent study aimed at assessing the prevalence of of low desire in this trial was due to the use of the FSFI, which
low sexual desire without (DSM Criterion A) and with distress focuses on the preceding 4-week interval, instead of interview
(DSM Criteria A and B; HSDD), West et al. (2008) used a assessment instruments which may focus on a longer recall
national probability sample to study the demographic factors period.
associated with low desire and HSDD in women aged 30–70 Recently, the Prevalence of Female Sexual Problems Asso-
who were in a relationship for at least 3 months. Data were ob- ciated with Distress and Determinants of Treatment Seeking
tained from 2,207 women through computer-assisted telephone (PRESIDE) study explored the prevalence of low desire in
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31,581 American women aged 18–102 (mean age 49) using the What is Sexual Desire?
question ‘‘How often do you desire to engage in sexual activity’’
and using the FSDS as the measure of distress (Shifren, Monz, One of the inherent challenges in defining sexual desire dis-
Russo, Segreti, & Johannes, 2008). Low desire (defined as never order relates to two factors (which may or may not be related):
or rarely desiring sexual activity) was prevalent in 38.7% of (1) the operational definition of sexual desire adopted by the
women and distress (defined as FSDS score[15) was observed DSM and used by clinicians/researchers and (2) the woman’s
in 22.8% of all women. The overall prevalence of low desire definition/understanding of her own desire. There are prob-
and associated distress was 10.0%. Poor self-assessed physical lems in the current operational definition of desire in the
health and depression were significant risk factors for low de- DSM that has implications for making an accurate HSDD
sire. In further analyses with this sample specifically exploring diagnosis. Specifically, there is a known discordance between
the predictors of distress, having a partner was the strongest women’s self-definitions of dysfunction and those applied
predictor (with an odds ratio of 4.6) (Rosen et al., 2009). Fur- by clinicians (King, Holt, & Nazareth, 2007).
thermore, sexual distress was highest in women with a partner Levine (1987) discussed the biological, cognitive, and emo-
who were sexually dissatisfied (as 71% of partnered women tional aspects of sexual desire. Ultimately, Levine (2002) de-
with low desire were in fact happy with their relationship). Age fined desire as the ‘‘sum of forces that incline us toward and
had a curvilinear effect such that low desire plus distress was away from sexual behavior.’’ However, this behavior-focused
highest in women aged 25–44 (despite the finding that actual proxy of sexual desire leaves us with an incomplete picture as to
rates of low desire were lowest in this group). Surgical meno- the true meaning of desire given that a lack of sexual activity may
pause, depression, use of hormonal therapy, and history of uri- relate more to partner characteristics (e.g., not having a partner,
nary incontinence were also significant predictors of distress. partner having no interest, partner too tired) than to the woman’s
Most recently, the second NATSAL was completed on own level of sexual desire (Cain et al., 2003). Also, some re-
6,942 British women aged 16–44 (Mitchell, Mercer, Wellings, search challenges this definition of desire as it has been shown
& Johnson, 2009). In response to a computer-assisted self- that many women engage in sexual activity without desire (Beck,
interview, 10.7% reported lacking interest in having sex for Bozman, & Qualtrough, 1991), women may engage/not engage
six months or longer in the past year. A further 27.9% of those in sexual activity for reasons unrelated to desire (Cain et al.,
sought help for the problem. Whereas increasing age, having 2003), and desire may be experienced in the absence of sexual
a child in the past year, and having children younger than age activity (Brotto, Heiman, & Tolman, 2009). Moreover, a review
five at home was associated with persistent lack of sexual of 38 studies found that there are enormous individual differ-
interest, seeking help was associated with being married and ences in the likelihood of, and preference for, sexual activity
perceiving a poor health. (Schneidewing-Skibbe, Hayes, Koochaki, Meyer, & Denner-
The marked variability in prevalence rates of low desire stein, 2008). In addition, whereas Levine (2002) stated that ‘‘we
suggests that identifying a single prevalence for the com- desire others for personal comfort by selecting members of the
plaint may be difficult and inaccurate. Disparate rates may correct gender, age, race, orientation, and degree of attractive-
relate to varying methodological techniques (e.g., interviews ness’’ (p. 40), more recent research in women shows a lack of
versus self-report questionnaires), different operational def- such target specificity in that women show a greater degree of
initions of low desire, different time periods during which the genital sexual response based on the sexual nature of the stim-
low desire is experienced (e.g., 1 month versus 6 months), ulus, and not on the gender or attributes of the person engaging in
and assessment across cultural groups (or subcultures) where the sexual activity (Chivers, Seto, & Blanchard, 2007).
the experience of desire may vary. Moreover, in a later sec- Among the validated measures of sexual desire, it is readily
tion on Recommendations, I review the implications for apparent that desire is conceptualized in a variety of different
including versus not including distress as a necessary crite- ways. For example, whereas the FSFI focuses on frequency and
rion for low sexual desire in women in light of the finding that intensity of ‘‘feeling sexual desire’’ (Rosen et al., 2000), the
there is a marked increase in the prevalence of low desire if Changes in Sexual Functioning Questionnaire has a multidi-
distress is not also taken into account. mensional focus on frequency of sexual activity, frequency of
Since the diagnostic criteria for HSDD were originally fantasy, experiencing enjoyment with erotic material, and plea-
available in DSM-III-R, the definition of HSDD has come sure when thinking about sex (Clayton, McGarvey, & Clavet,
under criticism and there have been solid efforts to propose 1997). In addition to these aspects of desire, the Sexual Interest
alternative definitions for this most common sexual com- and Desire Inventory also focuses on frequency of initiation and
plaint in women. Part of the challenge in coming to a con- receptivity to sex, satisfaction with desire, and responsive sexual
sensus definition on low sexual desire in women rests upon desire (Clayton et al., 2006). The Sexual Desire Inventory takes
establishing a unified definition of what sexual desire is (and a more cognitive approach to measuring desire and explores a
is not). The definition of desire is reviewed in the next section. variety of desire domains including: frequency of liking sexual
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Arch Sex Behav (2010) 39:221–239 225
activity, desire in response to seeing someone attractive, impor- women given an ICD-10 diagnosis agreed that there was a sexual
tance of ‘‘fulfilling’’ desire with sexual activity, strength of de- problem but 69% of women with no diagnosis agreed that there
sire for sex with a partner versus by oneself, etc. (Spector, Carey, was no problem. Age, ethnicity, employment, and recent sexual
& Steinberg, 1996). Collectively, this suggests that depending activity were unrelated to these associations.
on the measure used, definitions of desire may differ signifi- Interestingly, 19% of women did not receive an ICD-10
cantly. This has obvious implications for determining the preva- diagnosis but self-reported sexual difficulties and experienced
lence of self-reported desire concerns. low sexual satisfaction. This study suggested that the criteria
Although the DSM adopts a definition of desire that focuses used by clinicians to diagnose a sexual dysfunction may not
on absent or deficient sexual fantasies and desire for sexual be relevant to how women themselves define whether or not
activity, women themselves may not necessarily consider fan- they had a sexual problem. This finding has been supported
tasies and desire for sex to be a feature or element of how their by others. Bancroft et al. (2003) concluded that responses to
desire is expressed. In a recent qualitative study of mid-aged investigator-derived definitions of low desire differed from
women with and without sexual dysfunction, the majority of women’s own accounts of their sexual problems. Similarly, in
women did not discuss fantasies in their experiences of desire, another study of 290 British women aged 18–75, 79% indi-
although the vast majority did endorse having fantasies on a cated being very satisfied with their current sex life despite the
questionnaire (Brotto et al., 2009). Brotto et al. suggested that finding that 24% had not engaged in any sexual activity over
rather than fantasy being an expression of desire, some women the past 3 months (Dunn, Croft, & Hackett, 2000). The find-
may deliberately evoke fantasy as a way to boost their sexual ings from these studies suggest that the current assessment of
arousal. It follows, then, that the current DSM-IV-TR inclusion HSDD in women suffers from a high false positive rate when
of ‘‘lack of fantasies’’ in Criterion A for HSDD is problematic women are asked directly whether they feel they have a sexual
for overpathologizing women and needs to be critically evalu- dysfunction and that lack of sexual activity is an unreliable
ated. Also, when 3,262 multi-ethnic perimenopausal women indicator of sexual dissatisfaction. They also raise the possi-
were asked about their frequency of desire to engage in sexual bility that relative infrequency may be the preference for some
activity, 70% of the sample reported less than once a week; women. This was also suggested in a study showing that mid-
however, the majority (86%) were at least moderately to ex- life women’s sexual satisfaction was higher when their part-
tremely physically sexually satisfied (Cain et al., 2003). Simi- ner’s relative physical impairment precluded frequent sex (Avis,
larly, among 5,892 women with low desire and a partner, the Stellato, Crawford, Johannes, & Longcope, 2000).
majority (71.2%) were happy with the relationship (Rosen et al., A large body of research from The Netherlands (Both, Ever-
2009). Rosen et al. suggested, therefore, that focusing on the aerd, & Laan, 2003; Both, Spiering, Everaerd, & Laan, 2004;
frequency of desire is much less relevant to women than Everaerd & Laan, 1995; Laan & Everaerd, 1995; Laan, Ever-
focusing on the intensity of desire given that the former may aerd, van der Velde, & Geer, 1995) has supported an incentive-
relate more to lack of time and/or energy, or other factors. motivation model of sexual response, which has implications
There may also be differences in how clinicians/researchers for our understanding of sexual desire. This model argues that
define sexual desire compared to how women themselves de- motivation is not located ‘‘within’’ the individual but that it
scribe it. A study by King et al. (2007) compared the degree of emerges in response to sexual stimuli (Singer & Toates, 1987).
agreement between ICD-10 clinical diagnoses of sexual dys- As far as sexual desire is concerned, this research suggests that
function and women’s perceptions of their own sexual problems. all desire is triggered (i.e., responsive) and that the processing of
The Brief Index of Sexual Functioning for Women Question- sexual stimuli will prepare the person for action. An awareness
naire (BISF; Taylor, Rosen, & Leiblum, 1994), which provides of sexual desire occurs when feedback from the physiological
information sufficient to make an ICD-10 clinical diagnosis, was changes of arousal goes beyond the threshold of perception. A
administered to 401 women attending a general practice clinic in person’s ‘‘arousability’’ is their disposition to being able to be
the UK. Women were also asked if they thought they had any pushed towards sex, and this is thought to differ among indi-
kind of sexual problem and how distressing it was for them. viduals and be dependent on a number of neurophysiological,
Women who were and were not currently sexually active were personal, psychological, and cultural factors (Laan & Both,
included in analyses. Based on responses to the BISF, 38% of 2008). This research also suggests that increases in sexual
women were diagnosed with at least one ICD-10 sexual dys- arousal are accompanied by increases in sexual desire. Thus, the
function. Among women with an ICD-10 diagnosis who also distinction between sexual arousal and desire may be difficult, if
self-reported a sexual problem, the prevalence dropped to 18%. not impossible, which has implications for making a diagnosis
The prevalence dropped even further to 6% if women had the of a subjective sexual arousal disorder. Certainly, when women
diagnosis and also reported distress. There was more agreement are asked about the distinction between desire and subjective
between the diagnosis and self-report of problems for dyspa- arousal, many express conflation (Brotto et al., 2009). One way
reunia (74%) and vaginismus (77%) than for sexual arousal dis- that desire and arousal may be distinguished is that desire is
order (38%) and sexual desire disorder (39%). A mere 48% of the subjective experience of a willingness to behave sexually
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226 Arch Sex Behav (2010) 39:221–239
whereas arousal is the subjective experience of genital changes defined desire as ‘‘sensations that motivate individuals to
(Laan & Both, 2008; Prause, Janssen, & Hetrick, 2008). initiate or be receptive to sexual stimulation’’ and she divided
Supporting this incentive-motivation model of sexual desire these into spontaneous desire triggered by internal stimula-
in women are data which show the large number of cues which tion or sexual desire triggered by external stimulation (e.g.,
provoke sexual desire (125) and sexual activity (237) in women seeing an attractive partner). Thus, if a woman does not en-
(McCall & Meston, 2006, 2007; Meston & Buss, 2007). Engag- dorse sexual thinking or fantasies (presumably thinking and
ing in sexual activity ‘‘because the opportunity presented itself,’’ fantasies which are not first triggered by arousal or triggered by
‘‘because I was horny,’’ or ‘‘because the person was there’’ were her partner, her environment, or herself), then she would meet
unlikely reasons women provided for engaging in sexual activ- criteria for DSM Criterion A. A second aspect of Basson’s cri-
ity. (The most common reasons women provided for engaging tique focused on the linear nature of the Masters and Johnson/
in sex were: I was attracted to the person, I wanted to experience Kaplan sexual response cycle.Again summarizingthe research of
physical pleasure, It feels good, I wanted to show my affection others, Basson argued that desire and arousal emerge and are
for the person, and I wanted to express my love for the person; experienced simultaneously. Particularly for women in long-term
Meston & Buss, 2007.) Because the incentive-motivation relationships, where novel and powerful stimuli are less prevalent
model posits that all of sexual desire is triggered, this raises (Perel, 2006) this model states that sexual desire emerges after
concerns about the DSM-IV-TR Criterion A, which partly de- arousal, and not vice versa. In reality, the precise distinction be-
fines HSDD according to the lack of ‘‘sexual fantasies.’’ It has tween desire and arousal may not be entirely clear (e.g., Brotto
been argued that Criterion A describes a more ‘‘spontaneous’’ et al., 2009; Graham, 2009).
(i.e., untriggered) form of sexual desire, which may not be rel- Basson’s reconceptualization of the sexual response cycle
evant for many women (Basson, 2006). It is very interesting to for women focused on the motivations/incentives for initiating
note that in the DSM-IV Sourcebook in the section on sexual sexual activity, rather than spontaneous desire. In other words,
desire disorders, the subworkgroup had recommended that ‘‘it this views the infrequency or absence of spontaneous desire for
may be worth considering for a future DSM to further define sexual activity as a normative experience among many women
HSDD criteria to include the seeking out of sexual cues (or in long-term relationships. In fact, even among college-aged
awareness of cues)’’ (Schiavi, 1996, p. 1100). This recommen- students in a relationship of average length 13 months, 50% of
dation never made it into the final criteria set for HSDD in the the female participants reported having engaged in consensu-
DSM-IV-TR (American Psychiatric Association, 2000). al sexual activity without sexual desire in the past two weeks,
Over the past 10 years, Basson (2000) has published a series and 93% had done so at any time with their current partner
of expert opinion papers that provided clinical support for the (O’Sullivan & Allgeier, 1998). The most common reasons
incentive-motivation model of desire and which challenged the provided for engaging in sexual activity without sexual desire
Masters and Johnson/Kaplan model of women’s sexual re- were: the partner’s satisfaction and promotion of relational
sponse. Arguing from a clinical perspective, Basson stated that intimacy and prevention of relational discord. By extension, if
triggered sexual desire (which she terms ‘‘responsive desire’’) one adopts the view that sexual desire is triggered, then a more
more often reflects the experiences of women than spontaneous appropriate determination of low desire would be the woman
(i.e., untriggered) desire (Basson, 2001a, b, 2002, 2003, 2006). who never experiences sexual desire at any point during a
The motivational theory of desire, which portrays it as an action sexual encounter—before or after experiencing sexual arousal.
tendency to rewarding internal or external sexual stimuli, also There has been some support for this definition, focused on
supports desire which is responsive. Basson has described and responsive sexual desire, but there has also been notable criticism.
encouraged the adoption of an alternative sexual response cycle In support, a recent study on Malaysian women found a high
that is based on responsive sexual desire or desire that emerges degree of overlap in the desire and arousal domains of the FSFI
from a sexual situation, augmented only on some (possibly and these domains loaded onto one factor (Sidi, Naing, Midin, &
infrequent) occasions by initial or ‘‘spontaneous’’ desire. Her Nik Jaafar, 2008). Sidi et al. concluded that this provided support
critique emerged from earlier criticisms (e.g., Tiefer, 1991) against for the Basson circular model of sexual response given the high
the linear sexual response cycle proposed by Masters and degree of overlap between response phases. In a quantitative
Johnson and Kaplan, and adopted by the DSM. In particular, study of 141 community-recruited women aged 40–60, reports of
the Masters and Johnson and Kaplan model purports that spontaneous sexual thoughts were low and the majority of wo-
women (and men) first experience sexual desire before men, across menopausal categories, reported the frequency of
experiencing sexual arousal. Although the wording of HSDD sexual thoughts as mostly being ‘‘never’’ or ‘‘once/month’’ (Ca-
in the DSM does not make this explicit, many have inter- wood & Bancroft, 1996). An earlier random sample of 40-year-
preted the fact that the DSM is based on Masters and John- old Danish women found that a significantly greater proportion
son’s and Kaplan’s model to imply that desire is something of women endorsed sexual desire in response to something the
experienced at the beginning of a sexual experience, and partner did as opposed to having sexual desire at the outset (Garde
certainly prior to sexual arousal. In fact, Kaplan (1977, 1979) & Lunde, 1980). In the SWAN study, 78% engaged in sexual
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activity and the majority were physically, emotionally, and sex- Fantasy is another aspect of the current DSM criteria that
ually satisfied, experienced physical pleasure, almost always requires evaluation. Criterion A includes ‘‘persistently or recur-
experienced arousal, and usually did not have pain (Cain et al., rently deficient (or absent) sexual fantasies and desire for sexual
2003). The majority (77%) also reported that sex was moderately activity.’’ However, there are inadequate data available to support
to extremely important. Nonetheless, most of the women also had ‘‘lack of sexual fantasies’’ as a necessary feature of desire. Instead,
infrequent sexual desire (0–2/month). the available data suggest that absence of sexual fantasies (like
A model of sexual response that focuses on responsive desire lack of spontaneous sexual desire) may be rather normative
is open to criticism because it has never been directly empirically among the majority of women, and this may be without apparent
tested. In one study which attempted to compare which models of sexual dissatisfaction. Sexual fantasies and sexual satisfaction in
sexual response a group of 111 nurses (currently in a relationship) women are not found to correlate (Bancroft et al., 2003; Cain
endorsed, those women who identified with a written description et al., 2003). Fantasies, instead, are often deliberately (i.e., not
of the Basson model (compared to the Masters and Johnson spontaneously) evoked as a means of boosting sexual arousal
model or to the Kaplan model) had the lowest scores on the FSFI, (Beck et al., 1991; Hill & Preston, 1996; Lunde, Larsen, Fog, &
suggesting that the Basson model was only fitting for women with Garde, 1991; Purifoy, Grodsky, & Giambra, 1992; Regan &
extreme forms of sexual dysfunction (Sand & Fisher, 2007). Berscheid, 1996). Sexual fantasies in women decrease in fre-
However, the results were not surprising since Sand and Fisher quency with age (Purifoy et al., 1992). Moreover, there are ob-
used a measure of sexual desire that rewards spontaneous sexual served gender differences in the frequency of sexual urges (men
desire. This study importantly pointed out that women did not experience them more often), and men tend to have greater sexual
endorse one model of sexual response. More recently, an Aus- imagery (Jones & Barlow, 1990). The content of fantasies for
tralian study found that women with and without sexual dys- men and women differ, with men being more likely to have
function were equally likely to endorse a circular model of fantasies for activities they do not engage in and women having
responsive sexual desire (Giles & McCabe, 2009). In support of fantasies that correlate with their own actual experiences (Hsu
the circular model of responsive desire, other research exploring et al., 1994). Thus, it is possible that fantasies may be a construct
cues for sexual desire in pre- and post-menopausal women found more relevant to men’s sexual desire than women’s. As discussed
that most women endorsed a variety of ‘‘cues’’ which triggered in a later section, absence of fantasies as a necessary criterion for
their sexual desire, and the only factor that differentiated women HSDD is highly problematic.
with and without HSDD was that the former had fewer cues for
their desire (McCall & Meston, 2006, 2007). Among women in
the SWAN study (all of whom were in established relationships), Other Classification Systems
spontaneous sexual desire was an infrequent reason provided
for engaging in sexual activity, and lack of partner (not lack of Influenced by clinical evidence that women’s sexual desire is
desire) was the most frequent reason for not engaging in sexual responsive, and by the emerging psychophysiological data from
intercourse (Cain et al., 2003). In a separate set of analyses fo- The Netherlands, the International Classification Committee, a
cused on 2,400 women from this sample, 41.4% reported that convened international panel of experts in sexology practice and
they never or infrequently felt sexual desire (Avis et al., 2005). research, who met in 2002–2003 to make revisions to the DSM-
Despite this, 86% were moderately to extremely sexually satis- IV-TR criteria, offered the following definition of ‘‘Women’s
fied, and the majority reported no problems with sexual arousal. sexual interest/desire disorder’’:
In a more recent qualitative study of mid-life women with and
Absent or diminished feelings of sexual interest or desire,
without sexual dysfunction, Brotto et al. (2009) found that the
absent sexual thoughts or fantasies and a lack of responsive
majority of women in both groups could relate to a model of
desire. Motivations (here defined as reasons/incentives)
responsive sexual desire. It may be that the expression of desire
for attempting to become sexually aroused are scarce or
may differ as a function of assessment method (e.g., self-report
absent. The lack of interest is considered to be beyond a
questionnaires,providedwrittendescriptionsofdifferentmodelsof
normative lessening with life cycle and relationship dura-
desire, or assessed through qualitative interviews). In addition,
tion. (Basson et al., 2003)
none of the previously used validated measures of desire are based
on acceptance that responsive desire may normatively overshadow Although this revised definition has appeal in that it reduces
untriggereddesire(Althof,Dean,Derogatis,Rosen,&Sisson,2005). pathologizing of women who lack spontaneous sexual desire
Thus, there is both clinical and empirical support suggest- but who retain responsive sexual desire, a notable criticism is
ing that sexual desire is commonly a triggered (i.e., respon- that there is, at present, inadequate empirical data to support this
sive) experience and, therefore, a lack of spontaneous sexual definition of desire disorder in which lack of both spontaneous
desire should not be pathologized. In consideration of the and responsive sexual desire are necessary criteria. Again, based
DSM-V definition of sexual desire disorder, this finding must on the findings of Sand and Fisher (2007), women do not
be taken into account. unanimously endorse one model of sexual response. Of note, the
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composite Basson (2006, 2008) model allows for the known partner or relationship; 20% were problems resulting from
variability of women’s experience and flexibility of their sex- sociocultural, political, or economic factors; 8% were asso-
uality. Both responsive and spontaneous desire might contribute ciated with psychological factors, and only 7% were problems
in any one encounter to different degrees. However, if for a resulting from medical factors. This is the only study, to date,
given woman responsive desire is typically the major contri- providing a direct empirical test of the classification system
bution, this may be no more ‘‘dysfunctional’’ than if apparently outlined in The New View.
spontaneous desire governed her experiences, possibly leading Whereas the New View classification is an improvement
to risk taking, unhealthy relationships, or promiscuity and sub- over the DSM perspective of a linear model of sexual response
sequent distress. which is based on a medical model of men’s sexuality, it does
It is possible that a complete ‘‘overhaul’’ of the DSM clas- represent a radical departure from the DSM system, which may
sification system for sexual dysfunctions is needed. A different have implications for the continuity of research between the two
categorization of sexual dysfunction in women, stemming from systems. An overriding question exists: Is it useful to diagnose
a feminist perspective and anti-medicalization approach, pre- sexual dysfunction on the basis of causes rather than on the basis
ferred a system which completely removed the pathologizing of symptoms? In many cases of diagnosing a sexual dysfunc-
‘‘hypoactive sexual desire disorder’’ language. In response to tion, it is difficult, if not impossible, to ascertain the precise
a reductionistic view of women’s sexual problems and their etiological causes and many different causes interact with one
treatments, and the medical model which compartmentalizes another (Basson, 2006). Thus, if a problem of low desire is due to
mind-body influences, The Working Group for a New View of both medical and psychological factors, it is unclear how the
Women’s Sexual Problems (2000), chaired by Tiefer, offered New View would categorize this given that medical and psy-
a new classification scheme for women’s sexual dysfunction chological etiologies are on different domains. Moreover, the
that was a radical departure from the symptom-focused system DSM symptom criteria for all categories are not based on a
adopted by the DSM and ICD. Tiefer (2001) argued that a worri- presumed etiology but rather on symptom presentation. A dif-
some combination of mistaken claims (errors of commission) ferent, although related, alternative is to focus on the reason why
and leaving out too much information (errors of omission) people seek treatment for sexual difficulties, i.e., the distress
provided strong justification for the New View. (Nathan, 2003; L. Tiefer, personal communication, May 20,
In the New View, which was organized around the etiology 2009). A single disorder of Sexual Response Distress, and elim-
of women’s sexual problems, women could identify their own inating HSDD (as well as Female Sexual Arousal Disorder and
sexual problems, which they defined as ‘‘discontent or dis- Female Orgasmic Disorder) would capture the issue presenting
satisfaction with any emotional, physical, or relational aspect for treatment and would overcome the problematic and well-
of sexual experience.’’ Specifically, there are four categories of documented overlap between desire, arousal, and orgasm (as
sexual problems in the New View: (1) sexual problems due to reviewed by Graham, 2009). This intriguing idea deserves
sociocultural, political, or economic factors; (2) sexual prob- consideration.
lems relating to partner or relationship; (3) sexual problems Hartmann, Heiser, Ruffer-Hesse, and Kloth (2002) also
due to psychological factors; and (4) sexual problems due to proposed that a new classification system for women’s sexual
medical factors. The advantage of this model is that it avoids function be considered in light of the high degree of overlap
defining any one particular pattern of experience, focuses on among the different sexual dysfunctions. They suggested that
causation which would guide treatment, and is sensitive to the sexual problems were not the result of a single phase of a
important influence of sociocultural, political, and economic ‘‘virtual response cycle,’’ but, rather, sexual problems may be
factors that influence sexual function. In a recent study that due to a global lack of interest, arousability, and arousal. Thus,
explored the extent to which the New View framework cor- they suggested that sexual desire disorder be classified as being
responded with women’s accounts of their sexual difficulties, (i) in combination with sexual arousal disorder, (ii) in combi-
an open-ended questionnaire was administered to 49 British nation with orgasmic disorder, (iii) associated with depressive
women who were asked to describe their sexual difficulties in symptoms, (iv) associated with low self-esteem, and/or (v)
their own words (Nicholls, 2008). Using language equivalents associated with partner conflict. They also concluded that a new
and thematic content, women’s accounts of their difficulties classification system must take etiology into account. Unfor-
were divided into 108 distinct issues. Sixty-seven percent tunately, there has been no direct empirical test of the utility of
could be classified according to the New View system at a this proposed system; however, Hartmann et al.’s observation
subcategorical level. At a higher thematic level, 31% of dif- that sexual desire and (subjective) arousal are difficult to dif-
ficulties could be categorized which could not be categorized ferentiate, and may be experienced as one and the same for
at a lower, subcategory level. Overall, 98% of the sexual issues women (Brotto et al., 2009; Graham, 2009), is an issue that will
could be classified by the New View scheme. The majority be elaborated upon more fully later in this paper, and one that
(65%) of problems were classified as problems relating to should be considered for DSM-V.
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Arch Sex Behav (2010) 39:221–239 229
Deconstructing the DSM-IV-TR Criteria for HSDD on men, ejaculatory latencies were quantified with a stop-
watch but there is no analogue to this for measuring women’s
Specific features of the DSM-IV-TR (American Psychiatric desire.) As reviewed in an earlier section, validated ques-
Association, 2000) criteria for HSDD will now be considered tionnaires differ markedly on how desire is operationalized.
first with an attempt to highlight aspects of the definition that Such an attempt at objectively quantifying desire (and lack
should be preserved followed by specific recommendations thereof) in terms of intensity and frequency would also need
for change. Criterion A for HSDD requires ‘‘persistently or to be sensitive to potential cultural variations in how desire is
recurrently deficient (or absent) sexual fantasies and desire expressed. Sexual desire has been found to be significantly
for sexual activity’’ and Criterion B requires that ‘‘the dis- lower in East Asian compared to Euro-Canadian/American uni-
turbance causes marked distress or interpersonal difficulty.’’ versity samples (Brotto, Chik, Ryder, Gorzalka, & Seal, 2005)
Moreover, we are told that ‘‘the judgment of deficiency or as well as in population-based samples of mid-aged women
absence is made by the clinician, taking into account factors (Cain et al., 2003; Laumann et al., 2005), and increasing accul-
that affect sexual functioning, such as age and the context of turation to the mainstream culture is associated with increasing
the person’s life.’’ Criterion C indicates that the lack of sexual levels of sexual desire (Brotto et al., 2005). Moreover, there are
desire is not ‘‘better accounted for by another Axis I disorder cultural differences in sex guilt which specifically mediates the
(except another Sexual Dysfunction) and is not due exclu- relationship between ethnic group and sexual desire (Woo,
sively to the direct physiological effects of a substance or a Brotto, & Gorzalka, 2009). Whether sexual desire is indeed
general medical condition.’’ Following from these criteria, lower among East Asian compared to North American samples,
the issues to be considered, in turn, are (1) the meaning of or whether this finding is an artifact of cultural differences in
persistent and recurrent; (2) sexual fantasies and desire for how sexual desire is conceptualized, remains unknown. Thus,
sexual activity; (3) the disturbance causes marked distress the determination of optimal cut-off points for when low desire
and (4) interpersonal difficulty; (5) judgment of deficiency is is considered problematic must be sensitive to cultural nuances.
determined by the clinician; (6) not better accounted for by At present, there is no recommendation in the DSM to help
another Sexual Dysfunction; and (7) terminology of ‘‘hypo- guide the clinician to account for cultural factors in low desire.
active’’ and ‘‘desire.’’ At hand when considering the meaning of ‘‘persistent and
recurrent’’ is the issue of frequency and of severity in low
The Meaning of ‘‘Persistent and Recurrent’’ sexual desire. In the FSFI (Rosen et al., 2000)—the most
common self-report measure of sexual response in women—
Mitchell and Graham (2007) and Balon (2008) suggested that the desire domain is assessed as a composite of one question
a new diagnostic system must not overpathologize normal assessing the frequency of sexual desire and another question
variation and that the inclusion of objective cut-off points about the level (degree) of sexual desire. Whether a reduction
(e.g., frequency and duration) for symptoms may circumvent in sexual desire is experienced more often in duration or
this problem. The DSM-IV-TR text for HSDD indicates that severity, however, has never been empirically tested. In a
‘‘occasional problems with sexual desire that are not persis- series of papers by Balon (2008), Balon, Segraves, and Clayton
tent or recurrent or are not accompanied by marked distress (2007), and Segraves et al. (2007), one of their strong rec-
or interpersonal difficulty are not considered to meet criteria ommendations was that a duration criterion of 6 months or
for hypoactive sexual desire disorder’’ (American Psychiat- more be added to sexual dysfunctions. This time duration was
ric Association, 2000). However, persistent and recurrent are chosen given the finding of the NATSAL surveys (Mercer
not clearly operationalized in the DSM. This is not a unique et al., 2003; Mitchell et al., 2009) that lack of interest in sex in
feature of HSDD; rather, none of the sexual disorders are as- the past month was significantly more common (40.6%) than
sociated with specific criteria for frequency and/or duration. lack of interest lasting for six months (10.2%). Epidemio-
Recently, there have been efforts towards providing more logical data on the persistence of low desire for intervals
objective cut-off criteria for premature ejaculation (McMa- between one and six months are not available. Balon et al.
hon et al., 2008), but very little, if any, comparable data for the also recommended that the symptom of low desire be present
other sexual dysfunctions exist. By not including specific cut- in 75% or more of sexual encounters (Balon, 2008; Balon
off criteria for duration and frequency of symptoms, there is a et al., 2007; Segraves et al., 2007). This frequency corre-
danger of pathologizing normal variations in sexual desire sponds to the ‘‘usually always/always’’ criteria in the study
(Mitchell & Graham, 2007). Notably, data on the optimal by Oberg et al. (2004), who labeled these as ‘‘manifest dys-
frequency of low desire for designating desire disorder and function’’ and found them to be less common (29%) than
the specific duration of complaints have not been reported on ‘‘mild dysfunction’’ (i.e., rarely or sometimes present; 60%).
in the empirical literature. Also these are difficult data to However, among women who are not in relationships, the
obtain given that they would require a method of objectively relevance of the 75% criterion is questionable. For single
quantifying low desire that is reliable and valid. (In research women, it is possible that only the duration criteria would be
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230 Arch Sex Behav (2010) 39:221–239
considered. The addition of 6 months duration and 75% or bothered and experiences no distress over her loss of desire
more of sexual encounters appear to be reasonable objective whereas her partner is distressed. Using premature ejacula-
cut-points; however, the small number of studies on which tion as an example, it is obvious how the inclusion of distress
these recommendations are based suggests that they need to as a necessary criterion creates conceptual problems. Why
be directly tested for reliability and validity in field trials. should the man who ejaculates within 10 s of penetration not
be considered to have a sexual dysfunction on the basis of not
Sexual Fantasies and Desire for Sexual Activity being bothered by his abnormal sexual response? Similarly,
for the woman who cannot reach orgasm in any sexual situ-
As reviewed earlier, the inclusion of absent sexual fantasies ation and with any form of stimulation despite reaching a high
as a necessary criterion for HSDD is problematic given the level of sexual arousal: it is illogical for her not to receive a
low frequency with which untriggered fantasies occur in diagnosis of Female Orgasmic Disorder simply because she
women. There is also strong evidence that women deliber- is not bothered by her anorgasmia. From The New View
ately evoke fantasy as a means of boosting arousal. More- perspective, however, this position assumes that orgasm is a
over, as reviewed earlier, women with and without sexual normal/natural state and that its absence denotes pathology.
dysfunction provide many different reasons for engaging in With low desire, however, the picture is not as clear.
sexual activity and desire is but one. Thus, the absence of Distress seems more important to the delineation of whether
‘‘desire for sexual activity’’ may not be a sufficient marker of or not the symptom of low desire constitutes a problem or not
sexual desire disorder in women. It is possible that any and whether or not individuals will seek treatment. For
revision to the criteria for HSDD may include lack of sexual example, there is a small but growing body of literature on the
fantasy as one potential marker of low desire, but that there phenomenon of human asexuality (Bogaert, 2004, 2006;
are other ways in which low desire is manifested. Similarly, Brotto, Knudson, Inskip, Rhodes, & Erskine, 2008; Prause &
lack of desire for sex may be one way in which the woman’s Graham, 2007; Scherrer, 2008), defined as lifelong lack of
low desire is expressed. sexual attraction. Asexuals commonly do not experience
At present, HSDD is diagnosed according to monosymp- sexual desire; however, they are not distressed over the low/
tomatic criteria, i.e., if the woman experiences problems with absent desire. Asexuality has been described as a sexual
sexual fantasies and desire for sexual activity then she meets identity (Bogaert, 2006; Brotto et al., 2008) as opposed to a
the necessary symptom criterion A for HSDD. In consider- sexual dysfunction on the basis of finding that the only dis-
ation of the literature findings for the low baserate of spon- tress experienced by asexual persons is in reaction to socio-
taneous sexual fantasies, and that sexual activity is sought for cultural pressures to be sexual, and pathologizing those who
any number of reasons unrelated to desire, this calls for the do not wish to be sexual. The removal of distress from the
consideration of other criteria to define presence of a desire criteria for HSDD may lead to the unfortunate labeling of
disorder. This would require desire to be assessed according asexuals as having a sexual dysfunction and there is strong
to a predetermined number of symptoms taken from a vali- opposition to this view among the asexual community
dated list. The precise number of symptoms required for a (Brotto et al., 2008). Although research on asexuality is still
sexual desire disorder to be met would require validation in in its infancy, there is also insufficient evidence to suggest
field trials; however, some symptom possibilities based on that asexuality is a sexual dysfunction of low desire. I would
this literature review might include: lack of sexual thoughts, forward that the DSM-V consider making this point in the text
lack of sexual fantasies, lack of motivation to be sexual, lack or adding it to the list of exclusion diagnoses.
of initiation or receptivity to sexual activity with a partner, As reviewed in an earlier section and summarized in Table 1,
and lack of responsive sexual desire. the prevalence of low desire without distress is significantly
higher (in some cases double) than the rates of low desire with
‘‘The Disturbance Causes Marked Distress’’ distress. Hayes (2008) highlighted some important concep-
tual consequences of not including distress in the definition of
As reviewed earlier, there are obvious problems with HSDD in epidemiological research. Specifically, this review
including distress as a necessary criterion (Criterion B) for found that low desire and age are positively correlated (i.e.,
making a diagnosis of sexual desire disorder (Althof, 2001). complaints of low desire become more prevalent as women
‘‘Personal distress’’ as a criterion is problematic as it over- age); however, low desire, together with its associated dis-
emphasizes the role of the individual to the exclusion of tress, is not significantly associated with age (Bancroft et al.,
partner influences (Bancroft, Graham, & McCord, 2001; 2003; Hayes, 2008; Rosen et al., 2009). In analyses of both
Mitchell & Graham, 2007). ‘‘Interpersonal distress’’ is also European and American women participating in the WISHeS
problematic because it does not solve the problem of how to study, Hayes et al. (2007) found low desire to significantly
handle the diagnostic dilemma of whether to diagnose a increase with age but the proportion of women with low de-
sexual desire disorder in a situation where the woman is not sire who were distressed by it decreased with age, suggesting
123
Arch Sex Behav (2010) 39:221–239 231
that, perhaps, it is only younger women who may be dis- of ‘‘personal distress.’’ Discrepancies in partners’ levels of
tressed by their low desire. By including distress into the sexual desire are common in the clinical setting, reflecting an
symptom criteria, important information about the associa- interactional system of dyadic sexual desire (Heiman, 2001).
tion between low desire and age was reversed. Thus, the deci- Thus, for a diagnostic system to be clinically applicable, it
sion to include versus not include distress in the operational should take into account couple-level dysfunction. At pres-
definition of desire disorder will not only have implications ent, there is no way to document or quantify the extent of the
for determining its prevalence, but also for determining asso- relational influence on sexual dysfunction in the DSM-IV-
ciated risk factors. TR. However, it is interesting that ‘‘Relational Disorders’’
On the other hand, in the clinical setting, it is unlikely that a have been given consideration for DSM-V as being ‘‘serious
woman would seek treatment for her low desire unless she behavioral disturbances in a relationship of two or more
experienced some degree of personal and/or relational dis- people’’ (First et al., 2002). Moreover, in a table of proposed
tress. Indeed, the best predictor of distress with low desire relational disorders, First et al. list ‘‘Sexual Dissatisfaction’’
was relationship status (Rosen et al., 2009). Thus, in the as an empirically derived characteristic of marital relational
majority of clinical situations in which a DSM-V diagnosis disorders.
would be made, distress would likely be present. The issue of The DSM-IV-TR Criterion B for HSDD indicate that there
elevated levels of desire disorder if distress is no longer must be distress or ‘‘interpersonal difficulty.’’ Some have
considered part of the criteria, therefore, becomes more of an suggested that the relationship between sexual difficulties
issue in epidemiological and basic scientific research. and distress may be more a product of relationship influences
There may be alternatives to capturing distress that do as opposed to other potential predictors. It is known that
not require it to be a necessary symptom criterion. For ex- sexual problems can exist without distress, and that one may
ample, Mitchell and Graham (2007) recommended that dis- experience distress with no manifest sexual problems. The
tress could be included as a specifier (just as lifelong versus precise reasons for this are unclear; however, Bancroft et al.
acquired has been in the DSM-IV-TR). This option was (2003) noted that the occurrence of distress was closely
adopted by the 2003 Consensus Group (Basson et al., 2003). associated with relationship quality, and Rosen et al. (2009)
Another option to consider is whether distress could be in- found that relationship status was the single most predictive
cluded as a dimensional criterion for HSDD in which women factor accounting for distress in women with low desire. In
would be rated on a Likert scale corresponding to their level support of this are the findings that women linked their sexual
of distress. The inclusion of dimensional criteria in the DSM problems to emotional strain in the relationship (King et al.,
has been considered for many years in response to the 2007), sexual distress is associated with poor partner com-
problems of categorical decision making, and may be given munication (Hayes, Dennerstein, Bennett, & Fairley, 2008),
serious consideration for DSM-V (Kraemer, 2007; Rounsa- and there is an association between sexual distress and a
ville et al., 2002). Dimensional criteria may become a more partner’s sexual dysfunction (Byers & Grenier, 2003; Cayan,
common feature across many of the disorders within DSM-V. Bozlu, Canpolat, & Akbay, 2004; Oberg et al., 2004). In
Specifically, Kraemer (2007) suggested that a dimensional longitudinal work following women through the menopausal
adjunct could be added to a DSM criterion. Oberg et al. transition, relationship status and feelings for the partner
(2004) used the delineations of mild versus manifest dis- were significantly more predictive of sexual response than
tress and that may be one useful scheme to follow, with two other variables, including changes in estrogen (Dennerstein,
additional anchor points at the extreme ends. Thus, a woman Lehert, & Burger, 2005). In a recent study exploring the rela-
may experience (0) no, (1) mild, (2) manifest/moderate, or (3) tionship between partner compatibility (a broad term includ-
extreme distress associated with her low desire. It might also ing ability to communicate one’s needs, sharing emotions,
be possible to add as a specifier whether the distress was etc.) with sexual dysfunction in women, Witting et al. (2008)
personal or in regards to the woman’s relationship (cf. Ban- found compatibility items to be significantly associated with
croft et al., 2003). Clearly, the reliability and validity of a sexual distress. Having a partner who is more interested in sex
dimensional criterion of distress remains to be tested in field than the woman was a major predictor of low desire. Other
trials. significant compatibility factors for predicting low desire
were: partner not stimulating the right way, a belief that the
partner believes the woman is not ‘‘doing things the right
‘‘The Disturbance Causes Interpersonal Difficulty’’ way’’ during sex, the partner having sexual needs that the wo-
man believes she cannot satisfy, the woman having sexual
Mitchell and Graham (2007) argued that the DSM-V must needs that the partner cannot satisfy, and not finding the part-
avoid pathologizing normal variation. They noted that pre- ner attractive (Witting et al., 2008). Others have found sexual
vious recommendations (e.g., Basson et al., 2000) placed too compatibility to predict depression and sexual stress, and
much emphasis on the individual by including the criterion higher compatibility was associated with a greater likelihood
123
Table 1 Epidemiological studies assessing the prevalence of low desire in women
232
Study Sample characteristics Country Age In a sexual Method of assessment Distress measured Prevalence
relationship
123
Laumann et al. 1,749 women (NHSLS) United States 18–59 Had to be sexually In-person interview No 27–32% based on age group
(1999) active over the past
12 months
Fugl-Meyer and 1,335 women Sweden 18–74 Not necessary In-person interview Indirectly with the Sexual disability was defined as
Fugl-Meyer question: ‘‘Has this having low desire quite often/
(1999) been a problem in your nearly all the time/all the
sexual life during the time = 34%. Among these, 43%
last year?’’ viewed it as a problem
Mercer et al. 11,161 men and women Britain 16–44 Must have had at Computer-assisted No 40% had low desire for at least
(2003) (NATSAL) least one telephone-interview 1 month; 10% had low desire for
heterosexual at least 6 months
partner in past year
Bancroft et al. 987 women; half were United States 20–65 Not necessary Telephone audio Assessed distress over 7.2% prevalence of low desire
(2003) African-American computer assisted the relationship and
self-interviews. distress to one’s own
Desire assessed with sexuality
‘‘what is the frequency
with which you
thought about sex with
interest or desire over
the past month?’’
Oberg et al. 1,056 women recruited Sweden 19–65 Must have had sexual Face-to-face interview. Manifest distress: 60% mild low desire, 29% manifest
(2004) in 1996 intercourse once in Manifest low desire: Concomitant personal low desire, 44% low desire plus
past year low desire quite often, distress quite often, mild distress, 15% low desire
nearly all, or all of the nearly all the time, or plus manifest distress
time all the time
Laumann et al. 13,882 women recruited. 29 different countries 40–80 Must have had sexual Computer-assisted or No 26–43% across countries
(2005) Analyses based on intercourse once in face-to-face
9,000 sexually active past year interviews
women (GSSAB)
Leiblum et al. 952 surgically or United States 20–70 Currently sexually Questionnaire Measured with Personal 24–36% depending on age and
(2006) naturally active completion Distress Scale menopausal status. Among those
postmenopausal who also had distress, rates of
women (WISHeS) HSDD ranged from 9 to 26%
Dennerstein et al. 2,467 women (WISHeS) European countries— 20–70 Currently sexually Questionnaire Measured with Personal 16–46% depending on age and
(2006) France, Germany, active completion Distress Scale menopausal status. Among those
Italy, and United who also had distress, rates of
Kingdom HSDD ranged from 7 to 16%
West et al. (2008) 755 premenopausal, 552 United States 30–70 In stable Questionnaire Personal Distress Scale Overall rate of low desire 36.2%.
naturally menopausal, relationships for at completion Overall rate of HSDD 8.3%
and 637 surgically least 3 months
menopausal women
Arch Sex Behav (2010) 39:221–239
Arch Sex Behav (2010) 39:221–239 233
6 months or more. 27.9% of those

of using fantasy and overall higher levels of sexual desire and
FSDS cut-off score of 8.75, 23%

Using a FSFI cut-off score of 3.16,
34% had low desire, overall 10%
Distress not assessed but 10.7% reported lack of desire for

motivation (Hurlbert, Apt, Hurlbert, & Pierce, 2000).
55% had low desire. Using a
had low desire and distress
had low desire and distress

It is clear that partner influences on women’s sexual desire
are relevant to the diagnosis of sexual desire disorder. However,
the DSMs instruction that the clinician’s judgment guide the
assessment of whether relationship duration affects the sexual
sought help
dysfunction provides little guidance for making a diagnosis.
Prevalence
Consider the situation in which a woman desires sexual activity

once/month and her partner desires it twice/daily. The couple
may present for treatment with the initial complaint of her low
sexual desire. However, this is a case of desire discrepancy for
treatment seeking was

Female Sexual Distress
Female Sexual Distress
the woman’s low desire is only relative to her partner’s some-

Distress measured
what higher desire. Another illustrative situation is the case of

the woman who does not desire sexual activity from a partner
who is physically and/or emotionally abusive towards her. In
Scale
Scale
both of these scenarios, appreciating the relational influences

may change the decision as to whether a diagnosis of low desire
is given. One means of capturing the relational component may
you experienced a lack
‘‘In the last year, have
often do you desire to
sex for six months or

Questionnaires: Sexual
Desire assessed with
be with a dimensional criterion, as was proposed in the assess-

one question: ‘‘How
desire assessed with
of interest in having
Method of assessment
personal interview.
ment of distress. Such a ‘‘relational influences’’ specifier would

engage in sexual
Computer-assisted
capture, on a Likert scale, the extent to which relationship-

18–49 Must have engaged in Questionnaire
completion
activity?’’
related factors may be implicated in the etiology or maintenance

longer?’’
of the woman’s low desire. This may be quantified with (0) no,
(1) mild, (2) moderate, and (3) extreme relational influences. It is
obvious that the reliability and validity of this added dimen-
with a partner over
sional criterion would require empirical justification in field

the past 4 weeks
sexual activity
trials. Thus, the woman for whom a lack of sexual desire is

18–102 Not necessary
16–44 Not necessary
completely attributed to partner-related factors would still meet

relationship
In a sexual
criteria for a desire disorder; however, the clinical recommen-

dations may direct a treatment that is more oriented towards the
couple-level dysfunction if her relational influences score was
higher. This proposal is similar to the adoption of a relational
Age
contextual descriptor from the 2003 Consensus committee

(Basson et al., 2003).
The Judgment of Deficiency is Determined

by the Clinician
United States
Country
Finland
Britain
Criterion A of HSDD in the DSM-IV-TR (American Psychi-

atric Association, 2000) states that ‘‘The judgment of deficiency
or absence is made by the clinician, taking into account factors
Sample characteristics
that affect sexual functioning, such as age and the context of the
person’s life.’’ Although this statement lacks any recommen-
dation about how ‘‘judgment’’ is made, the qualities of the cli-
13,581 women
5,463 women
6,942 women
nician in making the judgment, and whether judgment possesses

PRESIDE
validity and inter-rater reliability, this statement does emphasize

the contextual (and relational) factors that may influence a
woman’s low desire. Similarly, the International Classification
Table 1 continued
Committee also recommended that ‘‘The lack of interest is

Mitchell et al.
Witting et al.
considered to be beyond a normative lessening with life cycle

Shifren et al.
(2008)
(2008)
(2009)
and relationship duration’’ (Basson et al., 2003). It has been

Study
established that sexual intercourse frequency declines with rela-

tionship duration (e.g., Christopher & Sprecher, 2000; Klusmann,
123
234 Arch Sex Behav (2010) 39:221–239
2002). Witting et al. (2008) also found that relationship in other women, it follows (Graham et al., 2004). In treatment
length and age were both associated with a higher prev- outcome research, psychological interventions for low desire
alence of sexual desire dysfunction, and that these two also significantly improve subjective sexual arousal (Hurl-
variables accounted for 13% of the variance in desire dys- bert, 1993). Indeed, some researchers conceptualize sexual
function. Klusmann (2002) explored relationship duration in desire entirely as the cognitive component of sexual arousal
almost 1,900 German university students and found that, for (Prause et al., 2008; Spector et al., 1996). Others prefer the
women, desire for sex declined and desire for tenderness term ‘‘arousability’’ to refer to sexual desire and subjective sex-
increased with relationship duration, whereas this pattern ual arousal, where sexual desire is considered to be an early
was not found for men. In addition, quality of marital sex is arousal process (Everaerd, Laan, Both, & van der Velde, 2000;
not necessarily correlated with relationship duration (Liu, Whalen, 1966). As reviewed earlier, Hartmann et al.’s pro-
2003). posed taxonomy suggests that there be one universal sexual
Clement (2002) proposed a systemic approach to under- desire disorder with specifiers denoting problematic arousal,
standing sexual desire in a long-term relationship that may have orgasmic function, mood, self-esteem, and/or relationship
implications for the DSM-V definition of desire disorder. He concerns. Additional research is needed to test this conclu-
argued that desire mismatch is an emergent function of the sion that sexual desire and subjective arousal may, in fact, be
couple’s communication and is not due to individual levels two sides of the same sexual coin. If this is the case, then
of desire within each member of the dyad. Importantly, such incorporating ‘‘arousability’’ into the criteria for low sexual
mismatches are more prevalent with relationship duration. desire is reasonable for DSM-V.
Not Better Accounted for by Another Axis I Disorder Terminology
Criterion C of HSDD in the DSM-IV-TR states that ‘‘The sexual Although the term ‘‘hypoactive’’ was introduced in the third
dysfunction is not better accounted for by another Axis I disorder edition of the DSM in 1980, there are problems with the label
(except another Sexual Dysfunction).’’ Thus, it is possible, and in hypoactive. It connotes a deficiency of activity and, therefore,
fact common, for women to experience more than one sexual unnecessarily emphasizes sexual activity as the central focus of
dysfunction (Fugl-Meyer & Fugl-Meyer, 2002). Epidemiologi- the loss of desire. Some interpret the ‘‘hypo’’ in HSDD to infer a
cal, laboratory, and clinical studies usually find a high degree of biological deficiency of testosterone (Burger & Papalia, 2006).
overlap between sexual desire and arousal disorders (Bozman & However, to date, the majority of studies (including two large
Beck, 1991; Slob, Bax, Hop, Rowland & van der Werff ten studies) have failed to find a correlation between low sexual
Bosch, 1996; Sanders, Graham, & Milhausen, 2008). However, desire and serum testosterone levels (Cawood & Bancroft,
Female Sexual Arousal Disorder (FSAD), according to the DSM- 1996; Davis, Davison, Donath, & Bell, 2005; Dennerstein,
IV-TR, focuses on ‘‘adequate lubrication-swelling response of Randolph, Taffe, Dudley, & Burger, 2002; Dennerstein et al.,
sexual excitement’’ and not on mental arousal—and it is the latter 2005; Gracia, Freeman, Sammel, Lin, & Mogul, 2007; Gracia
which is the more common clinical presentation. Additionally, et al., 2004; Santoro et al., 2005). Moreover, in many cases of
psychophysiological research has found that a perceived lack of presentation of low desire in a woman, it is apparent that the
genital arousal is usually not detected with objective measure- distress over her frequency of feeling desire is due to a dis-
ment, such as the vaginal photoplethysmograph (Laan, van Driel, crepancy in desired sexual activity between the woman and her
& van Lunsen, 2008), calling into question the validity of lubri- partner, as opposed to being attributable to a deficient level of
cation-swelling as a marker of sexual arousal. As a result, it has her own sexual desire. I am proposing, therefore, that ‘‘hypo’’ be
been suggested that a separate ‘‘Subjective Sexual Arousal Dis- removed from the diagnostic name of this condition.
order’’ be added to the taxonomy of female sexual dysfunctions Additionally, several epidemiological studies exploring
(Basson et al., 2003), to reflect the more common reason for the prevalence of low desire in women operationalize the
seeking treatment. The prevalence of subjective sexual arousal construct as a ‘‘lack of sexual interest’’ instead of ‘‘desire’’
problems is unknown given that it is rarely assessed in epidemi- (see Table 1). The term ‘‘interest’’ is preferred over ‘‘desire’’
ological studies (except Dunn, Croft, & Hackett,1999, who found as it emphasizes a broader construct than the more biological
a prevalence of 17%). ‘‘drive’’ connotations of sexual desire (e.g., Levine, 1987)
In reality, the distinction between subjective arousal and and it reflects the lack of motivation. Interestingly, Sexual
desire may be unclear at best (Graham, 2009). In part, this Interest/Desire Disorder was the preferred term adopted by
may be because women express difficulties differentiating the International Classification Committee on women’s
desire from subjective arousal (Brotto et al., 2009; Graham, sexual dysfunction (Basson et al., 2003). It is recognized that
Sanders, Milhausen, & McBride, 2004; Hartmann et al., this may not be the ideal term given that some feel that
2002). Also, in some women desire precedes arousal whereas ‘‘interest’’ is devoid of any sexual meaning.
123
Arch Sex Behav (2010) 39:221–239 235
Recommendations Table 2 Proposed criteria for Sexual Interest/Arousal Disorder (or

Sexual Arousability Disorder)
Two possible revised names for this disorder are Sexual Interest/ A. Lack of sexual interest/arousal of at least 6 months duration as
Arousal Disorder or Sexual Arousability Disorder. Both revised manifested by at least four of the following indicators:
titles reflect the common empirical finding that desire and (at (1) Absent/reduced interest in sexual activity
least subjective) arousal highly overlap. As reviewed earlier, (2) Absent/reduced sexual/erotic thoughts or fantasies
there are inconsistencies in how desire is defined, with some (3) No initiation of sexual activity and is not receptive to a partner’s
focusing on sexual behavior as an indicator of desire, some attempts to initiate
definitions focusing on spontaneous sexual thoughts/fantasies, (4) Absent/reduced sexual excitement/pleasure during sexual
activity (on at least 75% or more of sexual encounters)
and others emphasizing the responsive nature of women’s de-
sire. The DSM-IV-TR uses a definition of desire (i.e., sexual (5) Desire is not triggered by any sexual/erotic stimulus (e.g.,
written, verbal, visual, etc.)
fantasies and desire for sexual activity) that is highly problem-
(6) Absent/reduced genital and/or nongenital physical changes
atic for some women given that women adopt different models during sexual activity (on at least 75% or more of sexual
of sexual response (Sand & Fisher, 2007), and therefore loss of encounters)
anticipatory desire for sex may be relevant only to some women. B. The disturbance causes clinically significant distress or impairment
Given the strong tradition in the DSM of using a polythetic Specifiers
approach, here I argue that a polythetic approach also be used (1) Lifelong or acquired
in the diagnosis of Sexual Interest/Arousal Disorder or Sexual (2) Generalized or situational
Arousability Disorder, in line with most of the categories of (3) Partner factors (partner’s sexual problems, partner’s health
dysfunction throughout the DSM since DSM-III. status)
Based on the literature reviewed, the following criteria (4) Relationship factors (e.g., poor communication, relationship
might be considered in this definition: (1) absent/reduced in- discord, discrepancies in desire for sexual activity)
terest in sexual activity (preserving the DSM-IV definition); (5) Individual vulnerability factors (e.g., depression or anxiety,
(2) absent/reduced sexual or erotic thoughts or fantasies (pre- poor body image, history of abuse experience)
serving and expanding the DSM-IV definition); (3) does not (6) Cultural/religious factors (e.g., inhibitions related to
prohibitions against sexual activity)
initiate sexual activity and is not receptive to a partner’s ini-
(7) Medical factors (e.g., illness/medications)
tiation; (4) absent/reduced sexual excitement/pleasure dur-
ing sexual activity, and (5) desire is not triggered by any erotic
stimulus (e.g., written, verbal, visual, etc.). As reviewed by diagnosis of Sexual Interest/Arousal Disorder or Sexual Aro-
Graham (2009), because complaints of reduced genital and/ usability Disorder is that it takes into account the wide vari-
or non-genital excitement often co-occur with low desire, it ability across women in the experience of desire.
is recommended that this also be added as a sixth possible Specifiers would include: lifelong/acquired, generalized/
criterion (i.e., absent/reduced genital and/or nongenital phy- situational, and relational influences (measured dimension-
sical changes during sexual activity). The precise number of ally), which includes both partner factors (e.g., partner’s
these symptoms required in order to meet criteria for Sexual sexual or health problems) and relationship factors (e.g., poor
Interest/Arousal Disorder or Sexual Arousability Disorder communication, desire discrepancy). Whether generalized/
remains to be determined; however, it is reasonable to assert situational is preserved as a specifier or not requires addi-
that four of the six symptoms must be met (Table 2). The tional careful evaluation given that a situational dysfunction
(rare) situation in which complaints of impaired/absent may be an adaptive/normal reaction to a problematic context
genital arousal (A.6) occur despite a normal level of sub- and therefore should not be pathologized. Because criterion
jective desire/excitement would be classified as a Sexual C of the DSM-IV-TR definition of HSDD indicates that the
Dysfunction Not Otherwise Specified. diagnosis ‘‘is not due exclusively to the direct physiological
Thus, desire for sexual activity is acknowledged as being effects of a substance or a general medical condition’’ and
one of several possible markers of sexual desire. By adopting because a determination of exclusive cause can never be de-
a polythetic approach to the new desire disorder, this empha- termined in the case of low desire, I would argue that a new
sizes that the woman who lacks desire before the onset of specifier be added to the diagnosis which captures the clini-
sexual activity, but who is receptive to a partner’s initiation or cian’s impression as to whether medical factors play a role in
instigates for reasons other than desire and who does expe- the etiology (i.e., Medical factors). Moreover, given the
rience excitement during the sexual interaction would not recognition of the important influence of mood and increas-
meet criteria for a desire disorder. On the other hand, the ing data showing cross-cultural differences in the expression
woman who never experiences sexual desire, neither before of desire, two additional specifiers (e.g., individual vulnera-
nor during the sexual interaction, would meet criteria for the bility factors and cultural/religious factors) should be added.
disorder. The advantage to a polythetic approach for the Because of the marked elevation in rates of desire when a
123
236 Arch Sex Behav (2010) 39:221–239
more narrow window is defined (e.g., one month), I recommend American Psychiatric Association. (1987). Diagnostic and statistical
that these symptoms must be present for at least 6 months dura- manual of mental disorders (3rd ed., revised). Washington, DC:
Author.
tion and on at least 75% or more of sexual encounters. American Psychiatric Association. (2000). Diagnostic and statistical
Given the importance of distress, I do not advocate for the manual of mental disorders (4th ed., text rev.). Washington, DC:
removal of distress from the criteria. Instead, the low desire Author.
(indicated in Criterion A) must cause clinically significant Avis, N. E., Stellato, R., Crawford, S., Johannes, C., & Longcope, C.
(2000). Is there an association between menopause status and
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Across the Nation (SWAN). Menopause, 12, 385–398.
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proach, this recognizes that difficulties in women’s desire may change. Journal of Sex and Marital Therapy, 34, 186–197.
not be experienced in a uniform manner. Moreover, the re- Balon, R., Segraves, R. T., & Clayton, A. (2007). Issues for DSM-V:
quirement that there be at least four symptoms of problematic Sexual dysfunction, disorder, or variation along normal distribu-
tion: Toward rethinking DSM criteria of sexual dysfunctions. Amer-
desire/arousal for 6 months on the majority of sexual encoun- ican Journal of Psychiatry, 164, 198–200.
ters helps safeguard against the unfortunate situation where Bancroft, J., Graham, C. A., & McCord, C. (2001). Conceptualizing
adaptive decreases in desire may be inadvertently patholo- women’s sexual problems. Journal of Sex and Marital Therapy, 27,
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Bancroft, J., Loftus, J., & Long, J. S. (2003). Distress about sex: A
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It is apparent from this review that there has been much ex- Basson, R. (2001a). Using a different model for female sexual response
to address women’s problematic low sexual desire. Journal of Sex
cellent research in the domain of distress in women’s sexual
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Journal of Obstetrics and Gynaecology, 109, 357–363.
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Basson, R. (2003). Biopsychosocial models of women’s sexual
Sexual Interest/Arousal Disorder or Sexual Arousability Dis- response: Applications to management of ‘desire disorders’. Sex-
order will be essential. In addition, as I have proposed, objec- ual and Relationship Therapy, 18, 107–115.
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Basson, R. (2008). Women’s sexual desire and arousal disorders. Pri-
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Acknowledgments The author is a member of the DSM-V Work- J., et al. (2000). Report of the international consensus development
group on Sexual and Gender Identity Disorders. I wish to acknowledge congress on female sexual dysfunction: Definitions and classifica-
the valuable input I received from members of my Workgroup (Yitzchak tions. Journal of Urology, 163, 888–893.
Binik, Cynthia Graham, and R. Taylor Segraves) and Kenneth J. Zucker. Basson, R., Leiblum, S., Brotto, L., Derogatis, L., Fourcroy, J.,
Feedback from DSM-V Advisors John Bancroft, Rosemary Basson, Fugl-Meyer, K., et al. (2003). Definitions of women’s sexual
Ellen Laan, Marta Meana, and Leonore Tiefer is greatly appreciated. dysfunction reconsidered: Advocating expansion and revision.
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DOI 10.1007/s10508-009-9535-1
ORIGINAL PAPER
The DSM Diagnostic Criteria for Female Sexual Arousal Disorder

Cynthia A. Graham

Abstract This article reviews and critiques the DSM-IV-TR physiological changes that characterize the sexual response cy-
diagnostic criteria for Female Sexual Arousal Disorder (FSAD). cle’’ (p. 261). Utilizing the human sexual response cycle (HRSC)
An overview of how the diagnostic criteria for FSAD have model developed by Masters and Johnson (1966) as the frame-
evolved over previous editions of the DSM is presented and work, ‘‘inhibition’’ could occur at any one or more of the fol-
research on prevalence and etiology of FSAD is briefly re- lowing ‘‘phases’’: appetitive, excitement, orgasm, and resolution.
viewed. Problems with the essential feature of the DSM-IV-TR The most recent edition of DSM (DSM-IV-TR) (American
diagnosis—‘‘an inability to attain, or to maintain…an adequate Psychiatric Association, 2000) preserved this basic structure,
lubrication-swelling response of sexual excitement’’—are iden- classifying sexual dysfunctions into the following categories:
tified. The significant overlap between ‘‘arousal’’ and ‘‘desire’’ Sexual Desire Disorders, Sexual Arousal Disorders, Orgasmic
disorders is highlighted. Finally, specific recommendations for Disorders, Sexual Pain Disorders, Sexual Dysfunction due to a
revision of the criteria for DSM-V are made, including use of a General Medical Condition, Substance-Induced Sexual Dys-
polythetic approach to the diagnosis and the addition of duration function, and Sexual Dysfunction Not Otherwise Specified.
and severity criteria. The purpose of this article is to review and critique the DSM
diagnostic criteria for Female Sexual Arousal Disorder (FSAD).
Keywords Sexual arousal disorder DSM-V An overview of how the diagnostic criteria for FSAD have
Sexual problems Women evolved over the last three editions of the DSM will first be
presented. Following this, research on the prevalence and eti-
ology of FSAD will be reviewed, and the relationship between
Introduction arousal problems and distress discussed. Previous critiques of
DSM and revised definitions that have been put forward will be
reviewed. The specific diagnostic criteria for FSAD will be
…diagnostic categories are simply concepts, justified only
critically examined and key issues that should be considered for
by whether they provide a useful framework for organiz-
DSM-V identified. Finally, recommendations will be made for
ing and explaining the complexity of clinical experience in
revision of the criteria.
order to derive inferences about outcome and to guide de-
cisions about treatment. (Kendell & Jablensky, 2003, p. 5)
The third edition of the Diagnostic and Statistical Manual of Review of the Diagnostic Criteria for FSAD (DSM-III,
Mental Disorders (DSM) (American Psychiatric Association, DSM-III-R, and DSM-IV)
1980) was the first to include the category of Psychosexual Dis-
orders, defined as ‘‘inhibitions in sexual desire or the psycho- The DSM-III diagnostic criteria for ‘‘Inhibited Sexual Excite-
ment’’ are presented in Table 1. Note that, unlike subsequent
editions of DSM, the same diagnostic label was used for men
C. A. Graham (&)
and women. This reflected the assumption at the time that male
Oxford Doctoral Course in Clinical Psychology, Isis Education
Centre, Warneford Hospital, Headington, Oxford OX3 7JX, UK and female sexual response were similar and that vaginal lubri-
e-mail: [email protected] cation was the counterpart to male penile erection. Although the
123
Arch Sex Behav (2010) 39:240–255 241
Table 1 DSM-III diagnostic criteria for Inhibited Sexual Excitement Table 3 DSM-IV diagnostic criteria for Female Sexual Arousal Dis-
(302.72) order (302.72)
A. Recurrent and persistent inhibition of sexual excitement during A. Persistent or recurrent inability to attain, or to maintain until
sexual activity, manifested by completion of the sexual activity, an adequate lubrication-swelling
In Males, partial or complete failure to attain or maintain erection response of sexual excitement
until completion of the sexual act, or B. The disturbance causes marked distress or interpersonal difficulty
In Females, partial or complete failure to attain or maintain the C. The sexual dysfunction is not better accounted for by another Axis I
lubrication-swelling response of sexual excitement until disorder (except another Sexual Dysfunction) and is not due
completion of the sexual act exclusively to the direct physiological effects of a substance (e.g., a
B. A clinical judgment that the individual engages in sexual activity that drug of abuse, a medication) or a general medical condition
is adequate in focus, intensity, and duration Specify type
C. The disturbance is not caused exclusively by organic factors (e.g., Lifelong type
physical disorder or medication) and is not due to another Axis 1 Acquired type
disorder
Specify type
Generalized type
Situational type
DSM-III text described the excitement phase as consisting of Specify
‘‘a subjective sense of sexual pleasure and accompanying phys- Due to psychological factors
iological changes’’ (p. 276), the diagnostic criteria themselves Due to combined factors
only required impairment in genital arousal (penile erection in
the male and lubrication/swelling in the female).
In DSM-III-R (American Psychiatric Association, 1987),
the Sexual Arousal Disorders were subdivided into Male cence), the emphasis in the DSM-IV text also shifted to gen-
Erectile Disorder (302.72) and Female Sexual Arousal Dis- ital changes associated with sexual arousal. For example, the
order (302.72). There was one important change in the diag- ‘‘major’’ changes associated with sexual excitement were de-
nostic criteria for both sexes: Criterion A now required either scribed as: ‘‘vasocongestion in the pelvis, vaginal lubrication
impaired genital response (lubrication/swelling in the case of and expansion, and swelling of the external genitalia’’ (p. 494).
women, erection for men) or ‘‘persistent or recurrent lack of a The one mention of subjective response in the text on FSAD
subjective sense of sexual excitement and pleasure…during reflects the lesser importance ascribed to subjective pleasure and
sexual activity’’ (see Table 2). The DSM-III-R text noted that, excitement compared to genital arousal: ‘‘The individual with
‘‘In most instances there will be a disturbance in both the Female Sexual Arousal Disorder may have little or no subjective
subjective sense of pleasure or desire and objective perfor- sense of sexual arousal’’ (p. 501) (my emphasis). The Work
mance’’ (p. 261). Group recommended that rather than retain the concept of
In DSM-IV and DSM-IV-TR (American Psychiatric Asso- subjective excitement and pleasure in the diagnostic criteria,
ciation, 1994, 2000), lack of subjective excitement and pleasure diminished subjective sexual feelings be listed as an example
was dropped from Criterion A for both male and female arousal of a Sexual Dysfunction Not Otherwise Specified (SDNOS)
disorders. Thus, in women, the diagnosis of FSAD could be (302.70).
made solely on the basis of impairment of ‘‘an adequate lubri- It is interesting to consider the rationale for this increased focus
cation-swelling response’’ (see Table 3). In contrast with earlier on genital indicators of arousal and the removal of subjective
DSM-III and III-R texts (which referred to subjective pleasure feelings of sexual excitement and pleasure from the DSM-IV
and non-genital physiologic changes such as breast tumes- criteria. The DSM-III-R criteria were considered problematic for
two reasons: (1) the vagueness of the criteria and the extent to
which clinician judgement was required to make a diagnosis
Table 2 DSM-III-R diagnostic criteria for Female Sexual Arousal and (2) the combination of both subjective and physiological
Disorder (302.72) symptom criteria, particularly when studies had found poor con-
cordance between subjective measures of arousal and genital
A. Either (1) or (2)
measures, such as vaginal pulse amplitude (VPA), in women (Se-
(1) Persistent or recurrent partial or complete failure to attain or
maintain the lubrication-swelling response of sexual excitement graves, 1996a). Examination of the DSM-IV Sourcebook (Se-
until completion of the sexual activity graves, 1996a) reveals that, in the lead-up to DSM-IV, three
(2) Persistent or recurrent lack of a subjective sense of sexual options were considered: (1) deletion of the FSAD diagnosis (on
excitement and pleasure in a female during sexual activity the grounds that there was little evidence either of the clinical
B. Occurrence not exclusively during the course of another Axis I utility of the diagnosis or that FSAD existed as a ‘‘discrete syn-
disorder (other than a Sexual Dysfunction), such as Major Depression drome’’); (2) retention of the FSAD diagnosis and the DSM-III-R
criteria; (3) modification of the criteria so that Criterion A include
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242 Arch Sex Behav (2010) 39:240–255
only impaired vaginal lubrication and not subjective response. Background

Interestingly, although a literature review carried out supported
deletion of the FSAD category (Option 1), the Work Group Concept of Sexual Arousal and Underlying Mechanisms
recommended Option 3 on the grounds that this would maintain
‘‘compatibility between the sexes and between the DSM-IV and The term sexual arousal has been used in a variety of ways
ICD-10’’ (Segraves, 1996a, p. 1006). The Work Group recom- (Bancroft, 2005; Singer, 1984). Although some authors dis-
mendations pertaining to Male Erectile Disorder (ED) also called cuss sexual arousal as if it is synonymous with genital arousal,
for the diagnostic criteria to be modified so that only erectile the concept is much broader than this. It has been defined as ‘‘a
failure (and not reduced subjective excitement) was required. The state motivated towards the experience of sexual pleasure and
justification here was that in research studies the diagnosis of ED possibly orgasm, and involving (i) information processing of
was based on ‘‘objective criteria alone’’ and that, clinically, ‘‘there relevant stimuli, (ii) arousal in a general sense, (iii) incentive
is no evidence that men exist who have decreased sexual arousal motivation, and (iv) genital response’’ (Bancroft, 2005, p.
in the absence of desire or orgasm dysfunction’’ (Segraves, 411). A distinction can be made between the ‘‘state’’ of sexual
1996b, p. 1110). arousal and ‘‘sexual arousability,’’ with the latter referring to
The International Statistical Classification of Diseases and an individual’s disposition to respond to sexual cues with
Related Health Problems (ICD-10) (World Health Organization, sexual arousal, which varies across and within individuals
1992) does have a diagnostic category of ‘‘Failure of Genital (Bancroft, 2005; Laan & Both, 2008).
Response’’ (F52.2), but there is also a separate category labelled The Masters and Johnson HSRC model and Kaplan’s
‘‘Sexual Aversion and Lack of Sexual Enjoyment’’ (F52.1). Thus, (1974) model of human sexual response characterized sexual
although the Work Group sought ‘‘full compatibility with ICD- response as a universal, essentially linear progression from
10’’ (Segraves, 1996a), this was not, in fact, what was achieved sexual desire, through the stages of arousal, orgasm, and res-
by removing subjective excitement and pleasure from the FSAD olution. These stages were conceptualized as discrete phases,
criteria. with the possibility of specific impairments at any one or more
Another major change in DSM-IV was the inclusion of of the phases; as discussed above, the DSM-IV classification
Criterion B (i.e., the requirement that the problem causes system is based on this model. The HRSC model has received
‘‘marked distress or interpersonal difficulty’’); this criterion much criticism, particularly regarding its applicability to wo-
was added to the criteria sets for all the sexual dysfunctions in men (e.g., Boyle, 1994; Hartmann, Heiser, Ruffer-Hesse, &
DSM-IV. The relationship between distress and symptoms of Kloth, 2002; Levin, 2008; Tiefer, 1991).
FSAD will be discussed below. Focusing on incentive motivation, the model put forward by
Criterion C of DSM-IV criteria for FSAD restricted the Laan and Janssen (2007) defines sexual motivation as ‘‘the re-
diagnosis to those cases where ‘‘the sexual dysfunction is not sult of the activation of a sensitive sexual response system by
better accounted for by another Axis I disorder (except another sexually competent stimuli that are present in the environment’’
Sexual Dysfunction) and is not due exclusively to the direct (p. 329; see also Laan & Everaerd, 1995). Both sexual arousal
physiological effects of a substance…or a general medical and sexual desire are viewed as responses to a sexually relevant
condition.’’ stimulus. Sexual ‘‘desire’’ may reflect early arousal processes
In DSM-III-R (American Psychiatric Association, 1987), (Everaerd, Laan, Both, & van der Velde, 2000) and it is argued
subtyping (lifelong or acquired; generalized or situational; psy- that there is no such thing as spontaneous sexual desire (Laan &
chogenic only or psychogenic and biogenic) had been added. Both, 2008). Sexual thoughts or sexual activity act as stimuli,
Although these subtypes were retained in DSM-IV-TR, ‘‘psy- which then trigger the desire-arousal process. Individuals have
chogenic only’’ was renamed ‘‘due to psychological factors’’ variable tendencies to respond to sexual stimuli (often referred
and ‘‘psychogenic and biogenic’’ changed to ‘‘due to combined to as ‘‘arousability’’) (Laan & Both, 2008). While the drive mod-
factors.’’ el assumes that we have sex because we feel desire (Laan &
Although more precise duration and severity criteria were Janssen, 2007), the incentive motivation model instead suggests
considered by the DSM-IV Work Group for some of the sexual that we feel sexual desire because we have sex or think about sex
dysfunctions (e.g., ED) (Segraves, 1996b), the lack of empirical (Laan & Both, 2008). In other words, sexual thoughts or sexual
data on the relationship between severity and duration criteria activity act as stimuli, which then trigger the desire/arousal
and treatment outcome ruled this out. For FSAD, however, the process. Everaerd et al. (2000) suggested that, in comparison
DSM-IV text included this statement: ‘‘Occasional problems with men, genital changes might influence subjective experi-
with sexual arousal that are not persistent or recurrent…are not ence of sexual arousal in women to a lesser extent than external,
considered to be Female Sexual Arousal Disorder’’ (p. 501). contextual cues. There is now a considerable body of evidence
Similarly, a diagnosis of FSAD should not be given if the that supports this model (Both, Everaerd, & Laan, 2003; Laan
problems in arousal are ‘‘due to sexual stimulation that is not & Everaerd, 1995; Laan & Janssen, 2007; for review, see Toates,
adequate in focus, intensity, and duration’’ (p. 501). 2009).
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Arch Sex Behav (2010) 39:240–255 243
Another model of female sexual response, similar in some ‘‘lubrication-swelling’’ response, the focus in almost all of
ways to the incentive motivation model, was put forward by the research has been on the lubrication aspect, and not on
Basson (2000), who suggested that women most frequently genital ‘‘swelling,’’ which presents considerable challenges
engage in sexual activity not because of any intrinsic sexual in terms of measurement. Moreover, regarding lubrication
desire, but from a state of ‘‘sexual neutrality’’ and primarily difficulties, clinical and epidemiological research has relied
motivated by non-sexual reasons, such as desire for emotional almost exclusively on women’s subjective reports of lubri-
closeness with a partner. According to this model, a combi- cation, i.e., not on any objective measurement of lubrication.
nation of incentives for sexual activity, appropriate sexual Rather than measuring vaginal lubrication or swelling,
stimuli for the woman, and a context conducive to facilitating studies dating back to the 1970s investigating genital response
her arousal (e.g., privacy, lack of distractions, etc.) would in women have mainly assessed pulse amplitude in the vaginal
encourage the experience of sexual arousal. If this sexual wall (VPA), using vaginal photoplethysmography (Laan &
arousal was positive for the woman, this then triggered a Everaerd, 1995; Sintchak & Geer, 1975). There is now a large
‘‘desire’’ for her to continue the sexual encounter, now for both literature on VPA, although the methodology has a number of
non-sexual and sexual reasons. This emergent desire (which limitations (Levin, 2007). Increases in VPA occur quickly,
followed arousal) was termed ‘‘responsive sexual desire.’’ often within a few seconds, in laboratory studies where wom-
Basson (2000) also argued that sexual arousal in women is en are presented with erotic stimuli (Laan & Everaerd, 1995),
‘‘more a mental excitement, very much about the appreciation suggesting an ‘‘automatic’’ response (Laan & Both, 2008). A
of the sexual stimulus and less about the awareness of genital consistent observation has been that when subjective reports of
changes’’ (p. 63). arousal are correlated with VPA, the correlations are low in wom-
A study by Sand and Fisher (2007) challenged the idea that en (Chivers, Seto, Lalumière, Laan, & Grimbos, in press). In
there is one underlying ‘‘model’’ of sexual response that is contrast, in men, the degree of penile erection correlates
uniform across women. A group of 111 nurses were asked highly with subjective ratings of arousal and is usually always
which of three different models of sexual response—Masters significant. In women, the most consistent pattern found in
and Johnson’s (1966), Kaplan’s (1974), and Basson’s (2000)— laboratory studies is that VPA occurs in response to sexual
best represented their own experience. Approximately equal stimuli, but subjective sexual arousal is low or non-existent
proportions of women endorsed each of these three models and, (Everaerd et al., 2000). As Everaerd et al. (2000) observed,
interestingly, those women who endorsed the Basson model had ‘‘hardly ever was desynchrony between genital and sub-
lower scores on the Female Sexual Function Index (FSFI) jective sexual arousal found to be the result of subjective
(Rosen et al., 2000) (indicating worse sexual functioning) than sexual arousal without genital responding’’ (p. 122).
women endorsing one of the other two models. There has been an implicit assumption in the literature that
With regard to the endocrinology of sexual arousal, de- VPA is a measure of sexual arousal (Bancroft, 2009). However,
spite considerable research, our understanding of the rele- there is uncertainty about the relationship of increased vaginal
vance of hormones in women’s sexual arousal is still limited. blood flow to sexual arousal in women (Levin, 2003). Although
There is minimal evidence of a direct effect of estradiol on it is well established that VPA increases when women are ex-
sexual arousability in women (Dennerstein, Burrows, Wood, posed to sexual stimuli, as noted above, this response appears to
& Hyman, 1980; Sherwin, 1991). Although there has been be fairly ‘‘automatic’’ (and may occur even when the stimuli are
much interest in the role of testosterone in female sexuality, negatively evaluated by women) (Laan & Everaerd, 1995).
the evidence is inconsistent, compared to the male data, and More broadly speaking, it has been observed that, in com-
there appears to be considerable variability in women’s re- parison with men, genital arousal appears to be a less important
sponse to androgens (Graham, Bancroft, Greco, Tanner, & factor in women’s subjective sexual arousal (Laan & Everaerd,
Doll, 2007). The role of peptides, such as oxytocin and pro- 1995). There have been various explanations put forth for
lactin, is also uncertain (Bancroft, 2005). the reasons for this gender difference, including social learn-
ing theories and biological explanations (e.g., anatomical dif-
Assessment of Genital Response ferences between men and women) (Everaerd et al., 2000).
It is possible that other aspects of genital response (e.g.,
Assessment of genital response in women is considered dif- clitoral blood flow) may be better indices of sexual arousal.
ficult in comparison with that of men (Bartlik & Goldberg, There are other methods, such as labial thermistors, clitoral
2000). Levin (2003) pointed out that the relationship between ultrasonography, and pelvic magnetic resonance imaging (for
vaginal lubrication and sexual arousal is uncertain. Although review, see Janssen, 2001) but to date none of these have gained
lubrication does usually increase during sexual arousal, it widespread acceptance or been widely used. One major criti-
may not be maintained, especially after a lengthy period of cism has been the invasive methodology required for their
stimulation. It is also worth noting that although the essential placement on the genitals by the investigator. In two recent
criterion for a DSM diagnosis of FSAD is an inadequate studies (Kukkonen, Binik, Amsel, & Carrier, 2007, 2009), genital
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244 Arch Sex Behav (2010) 39:240–255
temperature (assessed using thermal imaging) was signifi- Nathan (1986) suggested that, to obtain true estimates of the
cantly correlated with subjective ratings of sexual arousal in population rates of FSAD, studies would need to assess the
women. However, there are practical difficulties (e.g., cost, adequacy of sexual stimulation experienced by women. DSM-
intrusiveness) with this measure. In addition, it has never been IV criteria also preclude a diagnosis of FSAD if the dysfunc-
used to compare genital arousal responses between women with tion is judged to be due exclusively to the physiological ef-
and without FSAD, so its diagnostic utility is unknown. fects of a substance or a general medical condition, including
In recent years, researchers have begun to utilize magnetic ‘‘menopausal or postmenopausal reductions in estrogen levels’’
resonance imaging (MRI) to study the anatomy of the female (p. 501). Because prevalence studies rarely obtain information
genital and pelvic organs during sexual arousal (Maravilla & on menopausal status, it is, therefore, important not to regard
Yang, 2008; Suh et al., 2004). Although this research is at an prevalence rates of lubrication problems as representing clinical
early stage, findings suggest greater variability of response in diagnoses.
women with FSAD, with some women showing virtually no Table 4 presents prevalence data reported by women from
response to sexual stimuli, and others showing responses that eight surveys. Most of these studies assessed problems with
are indistinguishable from women without sexual difficulties lubrication and not with ‘‘subjective’’ arousal or with other
(Maravilla & Yang, 2008). indices of genital arousal (e.g., swelling). Exceptions were the
study by Dunn, Croft, and Hackett (1998), which asked about
Prevalence of FSAD ‘‘problems being sexually aroused,’’ and the Bancroft et al.
(2003) study, which included a composite variable (labelled
In an early review of the epidemiology of DSM-III psycho- ‘‘impaired physical response’’) that comprised items on lack of
sexual dysfunctions, the prevalence of ‘‘Inhibited Sexual subjective arousal, lack of pleasant genital tingling, and lack of
Excitement’’ was said to be ‘‘indeterminate’’ for women be- enjoyment from genitals being touched. In a review of FSAD
cause so few studies had included questions about female prevalence data in European countries since the mid-1980s,
genital response (Nathan, 1986). Since the publication of Fugl-Meyer and Fugl-Meyer (2006) found no studies that
DSM-IV, there have been several large-scale epidemiological separated genital from ‘‘psychologic’’ arousal or that explicitly
surveys that have reported prevalence rates for lubrication combined genital and subjective arousal.
problems in women, many of which have used nationally As Table 4 shows, the estimated prevalence rates for lubri-
representative and cross-cultural samples. A criticism of ear- cation difficulties have varied widely. Although only assessed in
lier studies that claimed to have used DSM criteria to establish a small number of studies, the duration of sexual problems and/
sexual dysfunction was that they did not evaluate the presence or the recall period clearly affects prevalence rates (e.g., Mercer
of ‘‘marked distress or interpersonal difficulty’’ (Simons & et al., 2003; Oberg et al., 2004). Mercer et al. compared prev-
Carey, 2001). More recent studies have assessed the presence alence rates for sexual problems reported as lasting at least one
of associated distress or impairment (Bancroft, Loftus, & month in the past year (referred to here as ‘‘short-term’’) with
Long, 2003; Oberg, Fugl-Meyer, & Fugl-Meyer, 2004; Shi- those lasting at least six months (‘‘persistent problems’’) in the
fren, Monz, Russo, Segreti, & Johannes, 2008; Witting et al., last year. Although 9.2% of women reported short-term diffi-
2008). culties with lubrication, only 3.7% had persistent problems.
Notwithstanding these methodological improvements over Although Mercer et al. did not assess subjective feelings of
earlier studies, some of the criteria required to make DSM arousal, the difference in prevalence estimates between short-
diagnoses are difficult, if not impossible, to assess in large, term and persistent problems related to ‘‘lack of interest in sex’’
population-based surveys (Graham & Bancroft, 2006). For were striking (40.6% vs. 10.2%, respectively). Hayes, Den-
example, while not part of the diagnostic criteria, the DSM text nerstein, Bennett, and Fairley (2008) found that changing recall
states that ‘‘a diagnosis of FSAD is…not appropriate if the from ‘‘previous month’’ to ‘‘one month or more’’ increased
problems in arousal are due to sexual stimulation that is not prevalence rates for all female sexual dysfunctions.
adequate in focus, intensity, and duration’’ (p. 501). One of Almost all of the studies in Table 4 reported significant po-
the few studies that assessed complaints, such as ‘‘too little sitive relationships between age and lubrication difficulties
foreplay before intercourse,’’ was an early investigation by (e.g., Laumann, Paik, & Rosen, 1999; Najman, Dunne, Boyle,
Frank, Anderson, and Rubinstein (1978). A total of 100 married Cook, & Purdie, 2003; Richters, Grulich, de Visser, Smith, &
couples completed a self-report questionnaire that assessed the Rissel, 2003). However, few epidemiological studies have re-
presence or absence of sexual problems, such as ‘‘difficulty cruited older, postmenopausal women. One recent exception
getting excited’’ and ‘‘difficulty maintaining excitement.’’ was the Global Survey of Sexual Attitudes and Behaviors
Almost half (48%) of the women reported difficulty becoming (Laumann et al., 2005), which used computer-assisted tele-
sexually aroused and 33% reported difficulty with maintaining phone interviewing and postal questionnaires in a sample of
arousal. However, 38% of these women also reported too little 9,000 women aged 40–80 years from 29 countries. All of the
foreplay before sexual intercourse and 35% ‘‘disinterest.’’ women had intercourse at least once in the previous year. The
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Table 4 Prevalence of arousal problems in selected epidemiological studies
Arch Sex Behav (2010) 39:240–255
Study N of women Country Age Method of assessment Time period Prevalence
Bancroft et al. (2003) 987; all in heterosexual United States 20–65 Computer-assisted Previous month ‘‘Lubrication problems’’: 31.2%
relationships telephone interviewing ‘‘Impaired arousal’’: 12.2%
Dunn et al. (1998) 979 UK 18–75 Postal questionnaire Last 3 mos. Vaginal dryness: 28%
Arousal problems: 17.0%
Laumann et al. (1999) 1,749; all sexually active United States 18–59 Face-to-face interview Several mos. or more ‘‘Trouble lubricating’’: 20.6%
over last 12 mos. during past 12 mos.
Mercer et al. (2003) 4,826; all had at least 1 UK 16–44 Computer-assisted Past 12 mos. Trouble lubricating:
heterosexual partner self-interview Lasted at least 1 mo.: 9.2%
in last 12 mos.
Lasted at least 6 mos.: 2.6%
Najman et al. (2003) 908 Australia 18–59 Telephone interview Several mos. or more Trouble lubricating:
during past 12 mos. 21–30% (depending on age)
Oberg et al. (2004) 1,056; all sexually active Sweden 18–65 Structured face-to-face Past 12 mos. Insufficient lubrication:
during last 12 mos. interview ? questionnaires Manifest: 12%; Mild: 50%
Richters et al. (2003) 9,134 Australia 16–59 Computer-assisted At least 1 month in the Trouble with vaginal dryness: 23.9%
telephone interview past 12 mos.
Witting et al. (2008) 5,463 Finland 18–49 Questionnaires (FSFI ? FSDS) Past month Lubrication difficulties (met
FSFI cut-off of 4.31): 10.9%
Met FSFI cut-off and reported
distress: 7.0%
Note: manifest = ‘‘quite often’’, ‘‘nearly all the time’’, and ‘‘all the time’’; mild = ‘‘hardly ever’’ and ‘‘quite rarely’’
FSFI Female Sexual Function Index (Rosen et al., 2000); FSDS Female Sexual Distress Scale (Derogatis et al., 2002)
245
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246 Arch Sex Behav (2010) 39:240–255
overall prevalence of lubrication difficulties (occasionally, DSM-IV was a desire to maintain consistency between male and
periodically, frequently) varied from 16.1% (Southern Europe) female diagnostic categories, and between the DSM and ICD-10
to 37.9% (East Asia); the range for ‘‘frequent’’ problems was classification systems.
4.7–12.1%. Age showed a curvilinear relationship with the
likelihood of lubrication difficulties in most, but not all, coun- The Relationship Between Sexual Arousal
tries. Specifically, women aged 50–59 years were twice as like- and Sexual Desire
ly as those aged 40–49 years to report lubrication problems;
however, women in the oldest age group studied (70–80 years) As stated earlier, sexual desire, as an expression of incentive
were no more likely to have this complaint than the youngest age motivation, can be seen as the first component of sexual arousal
group (40–49 years). Although this study had several method- and may be experienced together with varying degrees of
ological problems (e.g., low response rate, differences in recruit- the other components (e.g., general arousal, genital response)
ment and method of assessment across sites), the findings under- (Bancroft, 2005). Hence, it is not surprising that in addition to
lined the importance of cultural factors in the experience of significant comorbidity between desire and arousal disorders,
sexual problems. there is also increasing support for the idea that arousal and
desire are not distinct phases of sexual response and are not
Comorbidity Between FSAD and Other Sexual experienced as such by women themselves. Evidence comes
Dysfunctions from a number of sources.
Qualitative research supports the idea that women often do not
In the DSM-IV text, under ‘‘Associated Features and Disor- differentiate between sexual ‘‘desire’’ or ‘‘interest’’ and ‘‘arousal’’
ders,’’ the issue of comorbidity was noted: ‘‘Limited evidence (Beck, Bozman, & Qualtrough, 1991; Brotto, Heiman, & Tol-
suggests that Female Sexual Arousal Disorder is often accom- man, 2009; Ellison, 2000; Graham, Sanders, Milhausen, &
panied by Sexual Desire Disorders and Female Orgasmic Dis- McBride, 2004). Further, contrary to the assumptions underly-
order’’ (p. 501). ing the HSRC model (Tiefer, 1991), there does not appear to be
There is now robust evidence indicating a high degree of any universal temporal sequence (e.g., from desire to arousal).
comorbidity between FSAD and other sexual disorders, par- Women sometimes report sexual interest preceding sexual
ticularly Hypoactive Sexual Desire Disorder (HSDD) (Basson arousal, and at other times following it (Graham et al., 2004).
et al., 2003; Fugl-Meyer & Fugl-Meyer, 2002; Laumann et al., Other studies have reported significant correlations between
1999; Rosen, Taylor, Leiblum, & Bachmann, 1993; Segraves & sexual desire and arousal (Beck et al., 1991; Sanders, Graham,
Segraves, 1991a). In one study of patients with HSDD, 41% of & Milhausen, 2008), and it has been suggested that sexual desire
the women had at least one other sexual dysfunction and 18% and arousal may be ‘‘two facets of the same process within the
had diagnoses in all three categories, i.e. desire, arousal, and sexual response’’ (Beck et al., 1991, p. 454). This suggestion is
orgasm (Segraves & Segraves, 1991a). A consistent observation consistent with the incentive motivation model. Laan and Both
in the literature has been that cases of FSAD seldom present on (2008) summarized evidence that the experience of sexual
their own or even as the ‘‘primary problem’’ (Bancroft, Graham, ‘‘desire’’ may follow from rather than precede sexual arousal
& McCord, 2001; Basson, McInnes, Smith, Hodgson, & Ko- and concluded that ‘‘…there is no good reason to assume that
ppiker, 2002; Heiman, 2002; Heiman & Meston, 1997; Meston feelings of desire and arousal are two fundamentally different
& Bradford, 2007; Rosen & Leiblum, 1995). In clinical settings, things’’ (p. 510). Laan and Both suggested that arousal and
it has been pointed out that sexual problems in women most desire might be distinguished on a phenomenological level in
often affect all phases of the ‘‘sexual response cycle’’ (Basson & that feelings of arousal might reflect the subjective experience of
Weijmar Schultz, 2007). Heiman (2002) noted that there were genital changes, and feelings of desire the ‘‘subjective experi-
no controlled treatment studies specifically related to FSAD. ence of an action tendency, of a willingness to behave sexually’’
As discussed earlier, questions about whether FSAD should be (p. 510).
considered as a disorder distinct from desire and orgasm were In contrast with men, studies involving clinical samples of
raised in the literature before DSM-IV was introduced (Segraves, women have also demonstrated a significant overlap between
1996a). In a clinical series of 532 women with sexual complaints, the dimensions of desire and arousal. For example, in their
40 (7.5%) met DSM-III-R criteria for having an arousal disorder; evaluation of the FSFI, Rosen et al. (2000) compared a group
however, the majority of these women also met criteria for de- of women diagnosed with FSAD with a group of women
sire or orgasm disorders. Indeed only eight women (1.5%) had without sexual complaints. In a principal components anal-
a single diagnosis of arousal disorder (Segraves & Segraves, ysis of the questionnaire items, the first component included
1991b). It was concluded that ‘‘The infrequency with which fe- measures of both sexual desire and arousal (particularly in the
male arousal disorder is a solitary diagnosis raises the question of FSAD group). It was observed that this finding ‘‘demon-
whether this should be retained as a diagnostic entity’’ (p. 9). As strates a considerable overlap between the dimensions
discussed above, the main reason that FSAD was retained in of desire and arousal in women, consistent with clinical
123
Arch Sex Behav (2010) 39:240–255 247
observation and contrasting with findings in studies of sexual prevalence of arousal problems with associated distress was
dysfunction in men’’ (p. 202). However, although acknowl- considerably lower (3.3–6.0%, depending on age). Physical
edging the overlap between desire and arousal, Rosen et al. health problems and current depression were associated with
stated ‘‘…a clinically based decision was made to separate increased odds of arousal problems, as was menopausal status.
the mixed factor of desire/arousal into two measurable Bancroft et al. (2003) assessed the prevalence of women’s
dimensions’’ (p. 202). distress about their sexual relationship, as well as distress about
In a study that sought to build a model of mid-aged women’s ‘‘their own sexuality’’ in the previous month. Among the wom-
sexual arousal, Dennerstein, Lehert, and Burger (2005) found en who complained of lubrication difficulties (31.2% of their
that items on women’s sexual responsiveness or arousal were sample), 7.3% reported ‘‘marked distress’’ about their relation-
not separable from items relating to sexual desire. Measures of ship and 6.5% about their own sexuality. In the overall sample,
sexual functioning developed for use with men (e.g., the Brief the best predictors of distress were indicators of emotional and
Index of Sexual Functioning (BISF)) (Taylor, Rosen, & Leib- relationship well-being and the quality of the emotional rela-
lum, 1994) have been found to have very different factor tionship with the partner. ‘‘Impaired arousal’’ (a composite
structures when they are modified for use with women. Heiman variable including genital symptoms but also subjective re-
(2001) noted that the female desire factor was ‘‘strikingly dif- sponse) was a relatively weak predictor of distress about the
ferent’’ on the female BISF questionnaire from the desire factors sexual relationship. It is noteworthy that lubrication and other
on the male questionnaire. Heiman concluded that ‘‘the results physical aspects of arousal, such as orgasm, were not signifi-
from these measures …strongly suggest that women’s sexuality cant predictors of distress, leading Bancroft et al. to conclude,
may be organized differently from that of men’’ (p. 120). ‘‘In general, the predictors of distress about sex did not fit well
In sum, although there is now good evidence that desire and with the DSM-IV criteria for the diagnosis of sexual dysfunc-
arousal in women are not easy to differentiate, they continue to tion in women’’ (p. 193).
be defined, and studied, as independent constructs (Graham King et al. (2007) compared ICD-10 clinical diagnoses of
et al., 2004). The primary reason for this appears to be the need sexual dysfunction with women’s own perceptions of whether
to maintain the continuity of the current DSM-IV classification or not they had a sexual problem and found a significant dis-
of separate desire and arousal disorders (Basson et al., 2000; cordance between the two. Overall, although 38% of women
Rosen et al., 2000), as well as the strong historical influence of were deemed to have an ICD-10 diagnosis of a sexual dys-
Masters and Johnson (1966), Kaplan (1974), and their asso- function, only 18% of women received a diagnosis and also
ciated models. perceived that they had a problem (and only 6% considered
their problem ‘‘moderate’’ to ‘‘severe’’). Four percent of wo-
Association Between Lubrication Problems and Distress men reported lubrication symptoms, but only 2% perceived
these as a problem, and even less (0.5%) regarded the problem
A number of recent studies have assessed personal distress as ‘‘somewhat’’ or ‘‘very’’ distressing. The lower prevalence of
(Criterion B) associated with sexual arousal difficulties (e.g., lubrication problems in this study may have been due to the
Bancroft et al., 2003; Hayes et al., 2008; King, Holt, & Nazareth, relatively young age of the sample (M = 37.8 years).
2007; Oberg et al., 2004; Shifren et al., 2008; Witting et al., Studies that have investigated the relationship between the
2008). A consistent finding across these studies has been that experience of sexual problems and ‘‘satisfaction’’ with sexual
sexual problems, even if moderate/severe, do not always cause relations have similarly found that women with sexual diffi-
distress. Although lubrication problems appear to be more fre- culties do not necessarily report dissatisfaction. In the study
quently associated with distress than other sexual problems discussed earlier by Frank et al. (1978), while close to half
(Oberg et al., 2004; Witting et al., 2008), in one study, 11% of (48%) of the married women in their sample reported ‘‘diffi-
women classified as having ‘‘manifest’’ lubrication problems culty getting excited,’’ 86% nonetheless described their sexual
(defined as experience of difficulties ‘‘quite often,’’ ‘‘nearly all relationship as ‘‘moderately satisfying’’ or ‘‘very satisfying.’’
the time,’’ or ‘‘all of the time’’) did not report any distress about Interestingly, however, ‘‘difficulty getting excited’’ was the
their symptoms (Oberg et al., 2004). In a study involving 31,581 sexual problem most strongly correlated with sexual dissatis-
U.S. women recruited through a national research panel (Shi- faction (r = .41); in comparison, difficulty in reaching orgasm
fren et al., 2008), distress was assessed with the Female Sexual (r = .22) and inability to have an orgasm (.18) were less
Distress Scale (Derogatis, Rosen, Leiblum, Burnett, & Heiman, correlated with sexual dissatisfaction. In a recent community-
2002). Women were classified as having ‘‘low arousal’’ if they based study of U.S. women aged 30–79 years, a 38.4% prev-
responded ‘‘never’’ or ‘‘rarely’’ to three questions: ‘‘How often alence rate of ‘‘sexual problems’’ was obtained, but only
do you become sexually aroused?’’, ‘‘Are you easily aroused?’’, 13.7% of the participants reported both sexual problems and
and ‘‘Do you have adequate lubrication?’’ While the age- dissatisfaction with their sex lives (Lutfey, Link, Rosen,
adjusted prevalence of current ‘‘low arousal’’ was 25.3%, the Wiegel, & McKinlay, 2009).
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248 Arch Sex Behav (2010) 39:240–255
Factors Underlying FSAD have called for alternative classification systems (Hartmann
et al., 2002; Tiefer, 2001).
Many possible causes of FSAD have been proposed, from phys- The Report of the International Consensus Development
iologic factors (e.g., hormonal, medication, vascular disease) Conference on Female Sexual Dysfunction (Basson et al., 2000)
to psychological factors (e.g., anxiety, depression, distraction) was written following a conference funded by the American
(for reviews, see Meston & Bradford, 2007; Nappi, Ferdeghini, Foundation for Urologic Disease in which 19 experts reviewed
& Polatti, 2006; West, Vinikoor, & Zolhoun, 2004). Prior to the the DSM-IV criteria. Regarding FSAD, the definition was ex-
introduction of sildenafil to treat male erectile problems, there panded to include nongenital and subjective dimensions of
was little investigation of possible physiological factors under- arousal. Sexual arousal disorder was defined as ‘‘the persistent
lying sexual arousal problems in women. In the last decade, or recurrent inability to attain or maintain sufficient mental excite-
there has been a focus on possible physiological causes of FSAD ment, causing personal distress, which may be expressed as a lack
(e.g., Berman & Bassuk, 2002; Nappi et al., 2006); despite this, ofsubjectiveexcitement, orgenital (lubrication/swelling)orother
any underlying pathophysiology of sexual arousal problems, if somatic responses’’ (p. 890). The rationale behind the recom-
it exists, is not well understood (Bancroft, 2009). mendation to change the DSM requirement from ‘‘marked dis-
Relationship difficulties and partner variables have con- tress and interpersonal difficulty’’ to ‘‘personal distress’’ was not
sistently predicted reports of sexual problems (Dennerstein clear.
et al., 2005; Witting et al., 2008) as well as associated distress In 2002 and 2003, an international multidisciplinary group
(Bancroft et al., 2003; Rosen et al., 2009). was convened to further review the definitions of women’s
Although reduced vaginal lubrication is often attributed to sexual dysfunctions and recommendations were made for ex-
low estrogen levels in postmenopausal women, there is some pansion and revision of diagnostic categories (Basson et al.,
evidence that vaginal atrophy but not vaginal dryness is asso- 2003, 2004). Regarding FSAD, criticism was directed at the
ciated with decreased estrogen (Laan & van Lunsen, 1997). DSM-IV focus on women’s genital response and the omission of
Based on findings from a longitudinal dataset involving 438 both subjective and non-genital physiological changes from the
Australian women who were followed through their meno- diagnostic criteria. The committee proposed the following three
pausal transition, Dennerstein et al. (2005) concluded that prior subtypes of FSAD: (1) Subjective sexual arousal disorder; (2)
sexual functioning and relationship variables were more pre- Genital sexual arousal disorder; and (3) Combined genital and
dictive of women’s sexual functioning than hormonal factors. subjective arousal disorder. The third subtype was viewed as
Findings from psychophysiological studies of sexual arousal also being the ‘‘most common clinical presentation’’ and was ‘‘usu-
suggest that arousal problems in healthy premenopausal women ally comorbid with lack of sexual interest’’ (p. 226). An impor-
are more often associated with inadequate sexual stimulation than tant addition to the definition of genital arousal disorder was that
with physical causes (van Lunsen & Laan, 2004). it included ‘‘marked loss of intensity of any genital response
Regardingpsychological factors,therehasbeenlessresearchon including orgasm’’ (i.e., the focus was not just on lubrication).
variables specifically associated with FSAD. Negative cognitions Other recommendations were to clarify the degree of distress (as
and attitudes about sexuality may make women more vulnerable none, mild, moderate, or marked) and to include the following
to experiencing arousal difficulties (Middleton, Kuffel, & Heiman, ‘‘contextual descriptors’’ of the diagnosis: (1) past factors (e.g.,
2008; Nobre & Pinto-Gouveia, 2006, 2008). Cognitive distraction negative upbringing, past trauma); (2) interpersonal difficulties
from erotic cues, sometimes induced by self-consciousness about (e.g., partner sexual dysfunction); and (3) medical and psychi-
body image (Dove & Wiederman, 2000), can also reduce sexual atric conditions, medications, or substance abuse.
arousal. There is evidence that a history of sexual abuse is more The above recommendations for revision of diagnostic
common among women with arousal difficulties (Laumann criteria preserve the main DSM-IV categories of desire, arous-
et al., 1999). al, and orgasm disorders. In contrast, the New View of Wo-
men’s Sexual Problems (The Working Group for a New View
of Women’s Sexual Problems, 2001), written by a group of
clinicians and social scientists, offered a new classification
Previous Critiques of DSM Criteria and Alternative system and a ‘‘woman-centered’’ definition of sexual problems
Classification Systems as: ‘‘discontent or dissatisfaction with any emotional, physical,
or relational aspect of sexual experience’’ (p. 5). Criticisms of
The DSM-IV classification system for female sexual dysfunc- DSM-IV were that it ignored gender differences in sexuality,
tion has received considerable criticism (Bancroft et al., 2001; relational aspects of women’s sexuality, and individual dif-
Boyle, 1994; Tiefer, 1996, 2001). Some authors have suggested ferences in sexual experience among women. The New View
revised definitions and diagnostic criteria, while preserving the classification system is not based on symptom criteria but or-
underlying structure of the DSM system, i.e., desire, arousal, ganized around four possible categories of causes: sociocul-
orgasm, and pain disorders (Basson et al., 2000, 2003). Others tural, political, or economic factors; partner and relationship
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Arch Sex Behav (2010) 39:240–255 249
factors; psychological factors; and medical factors. A study of Clayton, 2007). As reviewed above, prevalence studies on FSAD
49 British women (Nicholls, 2008) evaluated the utility of this have reported rates for short-term problems that are significantly
system. Women’s descriptive accounts of their sexual prob- higher compared to persistent problems (Mercer et al., 2003).
lems were analysed qualitatively and issues identified in their Although we have little empirical data comparing reports of
narratives compared with the New View categories. The sexual problems across different time periods, some authors have
findings suggested a ‘‘good fit’’; the majority of issues raised by recommended more specific duration and severity criteria (Ba-
women could be classified using the New View scheme. The lon, 2008; Balon, Segraves, & Clayton, 2007; Segraves et al.,
majority (65%) of women’s sexual difficulties were classified 2007). Specific recommendations for all of the sexual dysfunc-
as partner- or relationship-related problems. Although this was tions have been that symptoms should be present for 6 months or
a small study, it is the only study to date that has evaluated the more and occur in 75% or more of sexual encounters.
classification system, and the findings do provide some sup- The basis for choosing lubrication/swelling as the sole cri-
port for the clinical utility of the New View scheme. terion, and the omission of subjective excitement/pleasure from
Hartmann et al. (2002) also argued that a new classification the DSM-IV criteria set, was likely related to the erroneous
system for women’s sexual dysfunction was needed and that assumption that vaginal lubrication was the female equivalent
‘‘…by simply expanding and continuing DSM-IV criteria and the of male penile erection. As discussed above, there is evidence
traditional response cycle classification systems, it is impossible that increases in vaginal blood flow in women may be a rela-
to come to diagnostic categories and subtypes that adequately tively ‘‘automatic response’’ (Laan & Everaerd, 1995) and one
reflect real-life female sexual problems’’ (p. 85). Hartmann et al.’s that women may or may not be aware of (Bancroft, 2009).
major criticism of the DSM classification system, and also of the Although many authors attribute this emphasis on genital
revised Basson et al. (2000) definitions, was that female sexual response to Masters and Johnson (1966), their research demon-
problems do not relate to a single phase of a hypothetical response strated that many ‘‘extragenital’’ physiological changes occurred
cycle, but instead reflect ‘‘a more or less global lack of sexual during sexual arousal (e.g., myotonia, nipple erection). In their
interest, arousability, and arousal’’ (p. 85). Hartmann et al. also book on female sexual behavior, Kinsey, Pomeroy, Martin, and
recommended that a new classification system take etiological Gebhard (1953) also commented that ‘‘sexual responses obvi-
and comorbidity factors into account. In two empirical studies of ously involve a great deal more than genital structures’’ and that
women with low sexual desire, they found significant comor- ‘‘every part of the mammalian body may be involved whenever
bidity and high rates of psychological distress in their samples. there is sexual response, and many parts of the body may respond
Although Hartmann et al. made some suggestions for classifying as notably as the genitalia during sexual contact’’ (p. 623). Recent
hypoactive sexual desire disorders, including arousal complaints qualitative studies have likewise found that women report a wide
as a specifier for some desire disorders, they did not propose a range of physical (genital and nongenital), cognitive/emotional,
new classification system, emphasizing instead the need for a and behavioral changes with sexual arousal, with genital changes
better understanding of the mechanisms underlying sexual dis- only one dimension, and not necessarily the most salient one
orders and, in particular, more qualitative research of women’s (Brotto et al., 2009; Graham et al., 2004). In a focus-group study
experiences of sexual problems. of women aged 18–84 years (Graham et al., 2004), participants
described occasions where they experienced vaginal lubrication
but were not sexually aroused and other situations where they felt
sexually aroused but were not lubricated. Given that sexual
Critique of Specific DSM Criteria for FSAD
arousal clearly involves many physiological and psychological
changes, defining problems with sexual arousal only with ref-
Specific aspects of the DSM-IV-TR criteria for FSAD will
erence to impaired genital response appears problematic.
now be considered and recommendations made for revision.
Another major problem with the lubrication/swelling cri-
terion is that there is little evidence that women with arousal
Criterion A disorder have impaired genital response. In an early study,
Morokoff and Heiman (1980) found no significant differences
The essential feature of the diagnosis of FSAD is that there is in VPA between women diagnosed with sexual arousal dis-
insufficient vaginal lubrication/swelling (‘‘Persistent or recur- order and a control group of women. In a study of premeno-
rent inability to attain or to maintain until completion of the pausal women with sexual arousal problems, following sug-
sexual activity, an adequate lubrication-swelling response of gested definitions of Basson et al. (2003), women were clas-
sexual excitement’’). sified into three subtypes: genital, subjective, and combined
The requirement that symptoms be ‘‘persistent and recurrent’’ (subjective and genital) sexual arousal disorder (Brotto, Bas-
has been criticized as overly vague and likely to lead to undue son, & Gorzalka, 2004). Only those women in the ‘‘genital’’
reliance on clinician judgment, with negative consequences for subgroup, characterized by self-reports of impaired genital
both clinical and epidemiological research (Segraves, Balon, & sensitivity, showed evidence of impaired genital response. The
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250 Arch Sex Behav (2010) 39:240–255
VPA response of women with subjective or combined symp- Criterion B

toms (believed to constitute the majority of those who seek
treatment) did not differ from those of a control group of Criterion B requires that ‘‘the disturbance causes marked
women. Recently, Laan, van Driel, and van Lunsen (2008) distress or interpersonal difficulty.’’ There has been consid-
evaluated whether women diagnosed with FSAD using DSM- erable discussion in the literature regarding the distress criterion
IV criteria showed less genital response to visual sexual stimuli (Althof, 2001; Bancroft et al., 2003; Hayes, 2008; Mitchell &
than a control group of women without sexual problems. They Graham, 2007). Some have argued that personal or interper-
found no significant differences between the groups in VPA; sonal distress should not be included in the symptom criteria for
however, women with FSAD reported less positive and slightly the diagnosis of sexual dysfunction (Althof, 2001; Segraves
more negative affect in response to the erotic films. Laan et al. et al., 2007). The issue of distress is acknowledged to be a
concluded: ‘‘The sexual problems these women report are difficult one (Mitchell & Graham, 2007); on the one hand,
clearly not related to their potential to become genitally arou- logically it seems that lack of distress should not preclude a
sed…In medically healthy women, impaired genital respon- diagnosis from being made (and, as discussed above, we know
siveness is not a valid diagnostic criterion’’ (p. 1424). There is that some women meet diagnostic criteria for a sexual disorder
some evidence that VPA may be impaired in women who have but report no distress about it; King et al., 2007). On the other
chronic physical illness or following pelvic surgery. For hand, without assessing distress, prevalence rates for sexual
example, studies have reported that women with diabetes problems are markedly higher. Some epidemiological studies,
(Wincze, Albert, & Bansal, 1993) and women who had under- which have not assessed distress, have been criticized for pro-
gone radical hysterectomy for cervical cancer (but not those ducing estimates of ‘‘sexual dysfunction’’ that are widely agreed
having had simple hysterectomies) (Maas et al., 2004) had lower to be inflated. The best example of this was the publication in the
VPA in response to erotic films than control groups of women. Journal of the American Medical Association of a study on the
In support of the argument that women’s awareness of gen- epidemiology of ‘‘sexual dysfunction’’ (Laumann et al., 1999).
ital response should not be the central feature of the diagnosis of In this widely cited paper, 43% of women and 31% of men were
FSAD is the fact that phosphodiesterase type 5 inhibitor drugs identified as having a ‘‘sexual dysfunction,’’ described as ‘‘a
(PDE-5i), such as sildenafil (Viagra), met with little success in largely uninvestigated yet significant public health problem’’ (p.
controlled treatment trials involving women with FSAD (Bas- 544). A 43% prevalence rate of any dysfunction seriously calls
son et al., 2002; Laan, van Lunsen, & Everaerd, 2001). Although into question whether this is indeed pathology or the norm.
these drugs increased genital vasocongestion, this was not Distress was not assessed in this study and duration was oper-
associated with any perceived increase in subjective arousal by ationalized as ‘‘several months or more’’ during the past year.
women (Basson et al., 2002). As discussed earlier, studies have consistently reported lower
There is some evidence that the use of personal lubricants prevalence rates for sexual dysfunction when distress is required
has increased in recent years, both for enhancement of sexual (Hayes et al., 2008; Oberg et al., 2004; Witting et al., 2008) and
pleasure but also to treat problems with vaginal dryness the recall period used also affects prevalence estimates (Hayes
(Herbenick, Reece, Hollub, Satinsky, & Dodge, 2008; Herbe- et al., 2008).
nick et al., in press). The issue of lubrication difficulties may, In practice, an individual and/or their partner who is not
therefore, be less relevant today, given the wide availability of distressed by a sexual concern is unlikely to seek treatment
these products, at least in Western societies. It should also be (Bancroft et al., 2001). Also, Segraves et al. (2007) pointed out
noted that lubrication as a positive sign of sexual arousal is that the inclusion of the distress criterion in DSM-IV could be
culture-specific, as some societies, both in Africa and in the considered an unnecessary addition, given that the introduc-
Caribbean, value ‘‘dry sex,’’ i.e., the use of plants to dry and con- tory text makes explicit that a behavioral pattern can be con-
tract the vagina, for the purpose of increasing sensation for the sidered a psychiatric disorder only if it engenders distress or
man during intercourse (van Andel, Korte, Koopmans, Behari- disability. However, assessing distress in a clinical situation,
Ramdas, & Ruysschaert, 2008). including the distinction between so-called ‘‘personal’’ dis-
In summary, there is strong evidence that the criterion of tress and ‘‘interpersonal’’ distress, is clearly important and can
vaginal lubrication alone is insufficient to diagnose sexual inform treatment decisions.
arousal problems in women. The recommendations made be- A distinction might usefully be made between ascertaining a
low reflect the belief that a woman’s subjective awareness of sexual problem is present (based on self-report and behavior)
arousal should be a central component of the symptom criteria and diagnosing a ‘‘sexual dysfunction’’ on the basis of distress
and that additional genital and non-genital aspects of physio- and/or impairment in addition to the relevant symptoms. The
logical response, i.e., not simply lubrication/swelling, also be recommendation made here is that the requirement that distress
included. It seems crucial that diagnostic criteria adopted re- or interpersonal difficulty be present be retained as Criterion B;
flect the considerable heterogeneity of women’s experiences rather than a categorical assessment of whether distress is
of sexual arousal and individual differences across women. present or absent, the degree of distress that women (and their
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Arch Sex Behav (2010) 39:240–255 251
partners) are experiencing in relation to a sexual problem would Over a decade ago, Rosen and Leiblum (1995) commented that
be assessed on a dimensional scale (Regier, 2008; Widiger & ‘‘…the diagnostic nosology continues to be based on Kaplan’s
Samuel, 2005). model…despite a relative paucity of empirical support for this
model’’ (p. 879). There have been several revised definitions
Criterion C and modifications to diagnostic criteria put forward over the
last decade but, with one notable exception (The Working
Criterion C requires that ‘‘the sexual dysfunction is not better Group for a New View of Women’s Sexual Problems, 2001),
accounted for by another Axis I disorder (except another all of these have retained the basic DSM categories of desire,
Sexual Dysfunction) and is not due exclusively to the direct arousal, and orgasm disorders. Despite the recognition that
physiological effects of a substance (e.g., a drug of abuse, a using the HSRC as the framework for classifying women’s
medication) or a general medical condition.’’ This criterion sexual disorders is unsatisfactory, there has been a reluctance
seems both unrealistic (in that it is questionable whether it can to relinquish the diagnostic categories of desire, arousal, and
ever be established that a sexual problem is due exclusively to orgasm disorders and ‘‘return to the drawing board’’ (Mitchell
one or another cause) and inconsistent with more recent ap- & Graham, 2007). In an article on dilemmas in the pathway of
proaches to therapy, which emphasize the need for an inte- the DSM-IV, Carson (1991) discussed the dangers of ‘‘…tin-
grated approach (Graham & Bancroft, 2009). One example of kering on a superficial level with operational criteria that tend
this related to male ED is that the earlier focus on physical over time to approach the status of revealed truths, notwith-
causes and treatment using PDE-5i has shifted to a greater standing their often patently arbitrary nature and the unpro-
recognition of the importance of partner variables and rela- ductiveness of their outcomes’’ (p. 304). This concern seems
tionships in clinical management of cases (Fisher, Rosen, pertinent in the context of classification of women’s sexual
Eardley, Sand, & Goldstein, 2005; Heiman et al., 2007). problems; indeed, it appears that the categories of ‘‘desire’’ and
In view of the above, I suggest that Criterion C either be ‘‘arousal’’ disorders have been reified to some extent.
revised to acknowledge the fact that, in the majority of cases, In recognition of the empirical research suggesting a lack
the causes of arousal disorders are (1) multifactorial or (2) of differentiation between sexual desire and arousal in wo-
cannot be specified, or be deleted altogether. men and the high degree of comorbidity between FSAD and
HSDD, the proposal here is to merge these two diagnostic
DSM-IV-TR Diagnostic Subtypes categories. The suggested name for the disorder is Sexual
Interest/Arousal Disorder.
As mentioned earlier, DSM-IV provides subtypes to ‘‘indi- It is recommended that a polythetic approach to the diagnosis
cate the onset, context, and etiological factors associated with of this disorder be used, consistent with many other categories
the Sexual Dysfunctions’’ (p. 494). of dysfunction in the DSM. The advantage of this approach is
The first two of these subtypes, ‘‘lifelong’’ vs. ‘‘acquired’’ that it recognizes the heterogeneity inherent in women’s sexual
and ‘‘generalized’’ vs. ‘‘situational,’’ seem potentially useful experiences, and does not prioritize any one ‘‘type’’ of arousal
for clinical purposes, although it is worth noting that, in (e.g., genital, subjective, etc.). A preliminary list of proposed
epidemiological research, these distinctions have very rarely criteria is presented in Table 5. The precise number of symp-
been made. The recommendation made here would be to toms required in order to meet criteria for ‘‘Sexual Arousal/
retain these distinctions, although rather than include these as Interest Disorder’’ needs further consideration, and field trials
‘‘subtypes’’ they could instead be incorporated as specifiers should be conducted to evaluate what number and level of
(discussed further below). symptoms should be required for a diagnosis.
The final subtypes, ‘‘Due to Psychological Factors’’ and Although there has been little empirical data to inform the
‘‘Due to Combined Factors,’’ seem to be less relevant for choice of specific, severity, and frequency criteria, in view
either clinical or research purposes. As discussed above in of the evidence that mild and transient sexual problems are
relation to Criterion C, in practice it is often impossible to very common, and to avoid pathologizing normal variation in
ascertain the causes of sexual arousal problems and, in most sexual experiences (Segraves et al., 2007), it seems important
cases, both psychological and physical factors are implicated to specify some level of symptoms that are required for a
(Basson & Weijmar Schultz, 2007). diagnosis. Field trials should be set up to evaluate the validity
of using different severity/duration criteria.
Proposed Revision to DSM-IV Category of FSAD Specifiers
This review has highlighted the longstanding dissatisfaction A major recommendation in the present review is an expanded
that both researchers and clinicians have expressed about use of the category of specifiers. Specifiers are typically used to
the DSM-IV diagnostic criteria for female sexual dysfunction. ‘‘describe the course of the disorder or to highlight prominent
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252 Arch Sex Behav (2010) 39:240–255
Table 5 Proposed criteria for Sexual Interest/Arousal Disorder relationship discord, discrepancies in desire for sexual activ-
A. Lack of sexual interest/arousal, of at least 6 months duration, as
ity); individual vulnerability factors (e.g., depression or anxiety,
manifested by at least three of the following indicators poor body image, history of abuse experiences); and cultural/
(1) Absent/reduced interest in sexual activity religious factors (e.g., inhibitions related to prohibitions about
(2) Absent/reduced sexual/erotic thoughts or fantasies sexual activity). These specifiers are proposed based on previ-
(3) No initiation of sexual activity and is not receptive to a partner’s ous research that suggest these variables are ones that may be
attempts to initiate relevant to etiology and/or to choice of treatment.
(4) Absent/reduced sexual excitement/pleasure during sexual activity
(on at least 75% or more of sexual encounters) Acknowledgments The author is a member of the DSM-V Workgroup
(5) Absent/reduced genital and/or non-genital physical changes during on Sexual and Gender Identity Disorders. I wish to acknowledge the
sexual activity (on at least 75% or more of sexual valuable input I received from members of my Workgroup (Yitzchak
encounters) Binik, Lori A. Brotto, R. Taylor Segraves) and Kenneth J. Zucker.
Feedback from DSM-V Advisors Richard Balon, John Bancroft, Rose-
B. The disturbance causes clinically significant distress or impairment mary Basson, Marta Meana, and Leonore Tiefer is greatly appreciated.
Specifiers Reprinted with permission from the Diagnostic and Statistical Manual of
(1) Lifelong or acquired Mental Disorders V Workgroup Reports (Copyright 2009), American
Psychiatric Association.
(2) Generalized or situational
(3) Partner factors (partner’s sexual problems, partner’s health status)
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DOI 10.1007/s10508-009-9542-2
ORIGINAL PAPER
The DSM Diagnostic Criteria for Female Orgasmic Disorder

Cynthia A. Graham

Abstract This article reviews the DSM diagnostic criteria possible at any one or more of the phases of desire, excitement,
for Female Orgasmic Disorder (FOD). Following an overview orgasm, or resolution. The DSM-III diagnostic criteria for
of the concept of female orgasm, research on the prevalence ‘‘inhibited female orgasm’’ are shown in Table 1.
and associated features of FOD is briefly reviewed. Specific In DSM-IV and DSM-IV-TR (American Psychiatric Asso-
aspects of the DSM-IV-TR criteria for FOD are critically re- ciation, 1994, 2000), the concept of inhibition no longer fea-
viewed and key issues that should be considered for DSM-V tured and, accordingly, ‘‘Inhibited Female Orgasm’’ was re-
are discussed. The DSM-IV-TR text on FOD focused on the named ‘‘Female Orgasmic Disorder’’ (FOD). The essential
physiological changes that may (or may not) accompany or- feature of the disorder remained the persistent or recurrent
gasm in women; one of the major recommendations here is that delay in, or absence of, orgasm following a normal sexual
greater emphasis be given to the subjective aspects of the excitement phase. The major change in DSM-IV-TR was the
experience of orgasm. Additional specific recommendations added requirement that the problem cause ‘‘marked distress
are made for revision of diagnostic criteria, including the use of or interpersonal difficulty’’ (Criterion B) (see Table 2). One
minimum severity and duration criteria, and better acknowl- interesting change from DSM-III was the removal of the
edgment of the crucial role of relationship factors in FOD. statement (in Criterion A) that while inability to experience
orgasm during coitus in the absence of manual clitoral stimu-
Keywords Female Orgasmic Disorder DSM-V lation might represent a ‘‘normal variation of female sexual
Sexual problems Women response,’’ it could indicate a ‘‘pathological inhibition’’ that
would justify the diagnosis of inhibited female orgasm. Al-
Introduction though there was no explanation provided for why this text
was omitted from DSM-IV-TR, presumably it reflected a
In 1980, the concept of ‘‘psychosexual dysfunction’’ appeared desire to avoid pathologizing women who experienced or-
in the third edition of the Diagnostic and Statistical Manual of gasm from clitoral stimulation but not from intercourse (Hite,
Mental Disorders (DSM) (American Psychiatric Association, 1976; Tiefer, 2001). Criterion A in DSM-IV-TR highlights
1980). The term ‘‘psychosexual’’ was chosen to highlight the that ‘‘Women exhibit wide variability in the type or intensity
prevailing assumption at the time that psychological factors of stimulation that triggers orgasm’’ (p. 506) and there is no
were of crucial importance in the etiology of sexual problems attempt to specify the type of stimulation that is ‘‘normative.’’
(American Psychiatric Association, 1980, p. 261). DSM-III As such, women who experience orgasm through clitoral stim-
utilized the human sexual response cycle (HSRC) developed ulation but not during sexual intercourse do not meet criteria
by Masters and Johnson (1966) as the framework for classi- for a clinical diagnosis of FOD (Meston, Levin, Sipski, Hull,
fying sexual dysfunctions, with problems in sexual functioning & Heiman, 2004).
In DSM-III-R, subtyping (lifelong or acquired; generalized
or situational; psychogenic only or psychogenic and biogenic)
C. A. Graham (&)
was added (American Psychiatric Association, 1987). This
Oxford Doctoral Course in Clinical Psychology, Isis Education
Centre, Warneford Hospital, Headington, Oxford OX3 7JX, UK subtyping was retained in DSM-IV-TR, although ‘‘psycho-
e-mail: [email protected] genic only’’ vs. ‘‘psychogenic and biogenic’’ was renamed
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Arch Sex Behav (2010) 39:256–270 257
Table 1 DSM-III diagnostic criteria for Inhibited Female Orgasm The purpose of this article is to review the DSM diagnostic
(302.73) criteria for FOD. A brief overview of the concept of female
A. Recurrent and persistent inhibition of the female orgasm as orgasm, including definitional, sociocultural, psychological,
manifested by a delay in or absence of orgasm following a normal and physiological aspects, will first be presented. Following
sexual excitement phase during sexual activity that is judged by the this, research on the prevalence of FOD and possible etio-
clinician to be adequate in focus, intensity, and duration. The same
individual may also meet the criteria for Inhibited Sexual Excitement
logical factors will be reviewed. Critiques of the DSM criteria
if at other times there is a problem with the excitement phase of sexual will be discussed. The specific diagnostic criteria for FOD
activity. In such cases both categories of Psychosexual Dysfunction will be critically examined and key issues that should be
should be noted. considered for DSM-V identified. The paper will conclude
Some women are able to experience orgasm during noncoital clitoral with proposed diagnostic criteria for FOD.
stimulation, but are unable to experience it during coitus in the absence
of manual clitoral stimulation. There is evidence to suggest that in some
instances this represents a pathological inhibition that justifies this
diagnosis whereas in other instances it represents a normal variation of Background
the female sexual response. This difficult judgment is assisted by a
thorough sexual evaluation, which may even require a trial of treatment.
B. The disturbance is not caused exclusively by organic factors (e.g., Of all the various sexual responses, orgasm remains the
physical disorder or medication) and is not due to another Axis I most mysterious and least well-understood. (Bancroft,
disorder. 2009, p. 84)
Despite the fact that the extensive research on human or-
gasm has predominantly focused on orgasmic responsive-
Table 2 DSM-IV diagnostic criteria for Female Orgasmic Disorder
(302.73)
ness in women (Mah & Binik, 2001; Meston et al., 2004), the
above observation is particularly relevant to our under-
A. Persistent or recurrent delay in, or absence of, orgasm following a standing of women’s orgasm. Unlike orgasm in the male,
normal sexual excitement phase. Women exhibit wide variability in
the type or intensity of stimulation that triggers orgasm. The diagnosis which is usually accompanied by ejaculation, there is no
of Female Orgasmic Disorder should be based on the clinician’s equivalent objective ‘‘marker’’ of orgasm experienced by
judgment that the woman’s orgasmic capacity is less than would be women. Indeed women may find that it is difficult to recog-
reasonable for her age, sexual experience, and the adequacy of sexual nize if orgasm has occurred (Bancroft, 2009; Meston et al.,
stimulation she receives.
2004). In the male, there is an obvious reproductive function
B. The disturbance causes marked distress or interpersonal difficulty.
to orgasm, whereas it is generally accepted that female or-
C. The orgasmic dysfunction is not better accounted for by another Axis
I disorder (except another sexual dysfunction) and is not due gasm is not essential for reproduction. Many theories have
exclusively to the direct physiological effects of a substance (e.g., a been put forward for the existence of the female orgasm
drug of abuse, a medication) or a general medical condition. (Levin, 2005). Lloyd (2005) reviewed these theories and
endorsed the evolutionary ‘‘by-product’’ theory advanced by
Symons (1979). This postulates that although orgasm has
‘‘due to psychological factors’’ vs. ‘‘due to combined factors.’’ evolved for reproductive reasons in the male, its occurrence
Both DSM-III and DSM-IV-TR specified that a diagnosis of in females is due to the fact that there has not been any evo-
FOD would not be given if the orgasmic dysfunction was lutionary reason to suppress its expression.
better accounted for by another Axis I disorder (except an-
other Sexual Dysfunction), or was due exclusively to the di- Definitions of Orgasm
rect physiological effects of a substance, or a general medical
condition. The requirement that there be a ‘‘normal sexual After an extensive review of the literature, Mah and Binik
excitement phase’’ (Criterion A) implies that a diagnosis of (2001) concluded that ‘‘attempts to propose a universally
FOD should only be made if a woman has not been diagnosed accepted definition of ‘‘orgasm’’ have met with little suc-
with Female Sexual Arousal Disorder. In fact, however, in the cess’’ (p. 823). The lack of a satisfactory definition of orgasm
DSM-IV-TR section on ‘‘Differential Diagnosis,’’ is the has been attributed to our limited understanding of the
statement ‘‘Female Orgasmic Disorder may also occur in mechanisms underlying orgasm and our reliance on the
association with other Sexual Dysfunctions (e.g., Female subjective or self-report aspects of the experience (Meston
Sexual Arousal Disorder).’’ et al., 2004). Subjective descriptions of orgasm are extremely
In the International Statistical Classification of Diseases varied, suggesting that it is experienced in very different
and Related Health Problems (ICD-10) (World Health ways, both across individuals and on different occasions by
Organization, 1992) ‘‘orgasmic dysfunction’’ (F52.3) is de- the same individual. Some descriptions of orgasm suggest
fined as ‘‘orgasm either does not occur or is markedly de- altered consciousness; some describe multiple physical
layed,’’ without any additional diagnostic criteria. changes, whereas others may be very focused on genital
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258 Arch Sex Behav (2010) 39:256–270
sensations (Vance & Wagner, 1976). Despite the many orgasm rather than subjective changes. Mah and Binik (2001)
gender differences related to orgasm, the few studies that noted a dichotomization of the biological and psychological
have directly compared male and female experiences of or- perspectives on orgasm, with an emphasis on the former.
gasm have found striking similarities between them (Mah & Secondly, the DSM description suggests a ‘‘uniformity’’ of
Binik, 2001; Vance & Wagner, 1976). the objective indicators of orgasm, whereas research indi-
Early psychoanalytic theory posited that women who re- cates considerable variability across women (Meston et al.,
quired clitoral stimulation to reach orgasm were psychologi- 2004). For example, although Masters and Johnson (1966)
cally less ‘‘mature’’ than those who could reach climax during asserted that vaginal contractions always occurred with or-
intercourse (Freud, 1905/1953). Kinsey, Pomeroy, Martin, and gasm, later research demonstrated that not all women who
Gebhard (1953) and Masters and Johnson (1966) disputed this reported orgasm showed vaginal contractions (e.g., Bohlen,
view, and claimed that all orgasms in women were physio- Held, Sanderson, & Ahlgren, 1982; Levin & Wagner, 1985).
logically identical, regardless of the source of stimulation. These contractions also involve the pelvic floor surrounding
There is now good evidence that many women require clitoral the vagina, rather than the vaginal wall per se. Similarly,
stimulation to reach orgasm, and a relatively small proportion contractions of the anal sphincter accompanying orgasm
report that they always experience orgasm during intercourse have been found to occur in only a proportion of women who
(Lloyd, 2005). There are still, however, a few researchers who experience orgasms (Bohlen et al., 1982).
maintain that ‘‘clitoral’’ orgasm is somehow ‘‘inferior’’ to
‘‘vaginal’’ orgasm (Brody, 2007). Brody and Costa (2008) and Mechanisms Underlying Orgasm in Women
Costa and Brody (2007) have suggested that so-called ‘‘vagi-
nal’’ orgasm (as opposed to clitoral orgasm) is associated with While a review of the mechanisms underlying orgasm in
less use of ‘‘immature’’ psychological defence mechanisms women is beyond the scope of this article (for reviews, see
and higher satisfaction with mental health and relationships. Komisaruk, Beyer-Flores, & Whipple, 2007 and Meston et al.,
A number of typologies of orgasm have been proposed 2004), an examination of the literature makes it clear that
(e.g., Fisher, 1973; Singer & Singer, 1972), many of them fundamental questions about the mediation of orgasm remain
differentiating between orgasm experienced following clit- unresolved. For example, the extent to which orgasm is a
oral vs. vaginal stimulation. One long-standing controversy spinal phenomenon, depends on central events, or results from
has related to the Grafenberg (or ‘‘G’’-) spot, an area of erotic an interaction between central and spinal events is unclear
sensitivity in the anterior wall of the vagina that in some (Bancroft, 2009). It has been reported that approximately
women may be more responsive to ‘‘pressure stimulation’’ 50% of women following spinal cord injury are able to expe-
than touch. Levin (2003) concluded that there were likely rience orgasm (Meston et al., 2004), although Sipski, Alex-
three ‘‘erogenous sites’’ in this area of the vagina, which he ander, and Rosen (2001) found that those with complete lower
called the ‘‘anterior wall erogenous complex.’’ A recent motor neuron injuries affecting their S2-5 reflex arc were
ultrasound study of the clitoris suggested that the special significantly less likely to experience orgasm. There is other
sensitivity of the area called the G-spot might be explained by evidence that women can experience orgasm with no direct
pressure and movement of the clitoris’ root (Foldes & Buis- genital stimulation (Heiman, 2007). Studies on brain imaging
son, 2009). What is still unclear is what proportion of women that have investigated brain activity during orgasm (Ko-
experience localized erotic sensitivity in this area. misaruk et al., 2002; Komisaruk & Whipple, 2005) have
Recent research that has investigated physiological changes suggested that the most important activation sites for orgasm
in female genital sensation during sexual stimulation has may be the paraventricular nucleus, the central gray area of
demonstrated that vibratory thresholds in the clitoris and the midbrain, the cerebellum, and the hippocampus (Heiman,
anterior vaginal wall decrease during arousal and orgasm, with 2007).
sensory thresholds returning to baseline levels 20 min after
orgasm (Gruenwald, Lowenstein, Gartman, & Vardi, 2007). Historical and Cultural Aspects of Orgasm
In the DSM-IV-TR text on FOD, the orgasm phase is de-
scribed as ‘‘…a peaking of sexual pleasure, with release of Heiman (2007) discussed the evolution of medical and soci-
sexual tension and rhythmic contraction of the perineal etal perspectives on female orgasm and concluded that the
muscles and reproductive organs…. In the female, there are current perception of lack of orgasm in women as a problem
contractions (not always subjectively experienced as such) of that requires treatment is in part a ‘‘cultural accident’’ (p. 87).
the wall of the outer third of the vagina. In both genders, the In some historical periods, orgasm in women has not been
anal sphincter rhythmically contracts’’ (p. 494). considered acceptable. In the 1920–1930s, the emphasis on
There are two noteworthy aspects of the DSM definition. ‘‘marital adjustment’’ resulted in men thinking that their part-
Firstly, apart from the ‘‘peaking of sexual pleasure’’, the ners should experience orgasm, putting them under pressure
description focuses on physiological changes associated with in the process (Dickinson & Beam, 1931). Many feminists
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Arch Sex Behav (2010) 39:256–270 259
have argued that the current emphasis on women’s ‘‘right’’ to Prevalence of Orgasmic Problems in Women
orgasm has had negative consequences for women (Potts,
2000; Tiefer, 1991). It has been suggested that the undue In the last decade, there have been several large-scale epi-
emphasis on orgasm for women as the goal and ‘‘natural’’ demiological surveys that have reported prevalence rates for
endpoint of sexual activity has been ‘‘enshrined’’ in the DSM orgasmic problems in women. Many of these have used
(Tiefer, 2001). nationally representative samples, an improvement over
In addition to historical shifts, there are also very signifi- earlier studies that often relied on convenience or clinical
cant differences across cultures in the perspectives on female samples. Simons and Carey (2001) reviewed the literature on
orgasm. While few studies have compared prevalence of or- the prevalence of sexual dysfunction and highlighted several
gasmic problems in women from different cultures, those that methodological problems. For example, although many
have done so have reported marked cultural differences (e.g., studies claimed to have used DSM criteria to establish sexual
Laumann et al., 2005). In the DSM-IV-TR text on FOD, there dysfunction, few assessed the presence of ‘‘marked distress
is no mention of cultural factors being an important consid- or interpersonal difficulty’’ or the absence of an Axis I dis-
eration (although the introductory text on ‘‘Sexual Dysfunc- order (both essential criteria for a DSM-IV-TR diagnosis).
tions’’ does state that ‘‘Clinical judgments about the presence More recent studies have made attempts to assess women’s
of a Sexual Dysfunction should take into account the indi- distress about sexual difficulties (Bancroft, Loftus, & Long,
vidual’s ethnic, cultural, religious, and social background, 2003b; Oberg, Fugl-Meyer, & Fugl-Meyer, 2004; Shifren,
which may influence sexual desire, expectations, and atti- Monz, Russo, Segreti, & Johannes, 2008; Witting et al.,
tudes about performance’’ (p. 495). 2008). However, some of the criteria required to make DSM
diagnoses are difficult if not impossible to establish in large,
Developmental and Gender Aspects of Orgasm population-based surveys (Graham & Bancroft, 2006). For
example, surveys have not assessed whether women have
A woman’s first experience of orgasm can occur any time experienced a ‘‘normal sexual excitement’’ phase, a re-
from the prepubertal period to well into adulthood (Bancroft, quirement of Criterion A for the diagnosis of FOD. While
Herbenick, & Reynolds, 2003a). While in boys the age of first some researchers have acknowledged that responses to sur-
orgasm is closely tied to puberty, girls show a much more vey questions are not the same as a clinical diagnosis, and
variable pattern (Kinsey et al., 1953). In Kinsey’s original because of this have used the term ‘‘sexual difficulties’’ or
data, 23% of women reported having experienced orgasm by ‘‘sexual problems’’ rather than ‘‘sexual dysfunction’’ (e.g.,
age 15, 53% by age 20, 77% by age 25, and 90% by age 35. Bancroft et al., 2003b; Richters et al., 2003), others (e.g.,
Kinsey estimated that approximately 9% of women did not Laumann et al., 1999) have been less cautious. This issue of
experience orgasm throughout their lifetime. terminology is an important one, because claims that up to
In the U.S. National Health and Social Life Survey 43% of American women have a sexual dysfunction (e.g.,
(NHSLS), Laumann, Gagnon, Michael, and Michaels (1994) Laumann et al., 1999) have been widely cited in both the
found that women’s rates of orgasm consistency (defined as media and the scientific literature (Graham & Bancroft,
‘‘usually or always’’ experiencing orgasm) were higher dur- 2006).
ing masturbation than during sexual activity with a partner. Table 3 presents prevalence data on orgasmic problems
About 60% of women reported that they ‘‘usually’’ or ‘‘always’’ reported by women from 11 surveys, all of which used
had an orgasm when masturbating, compared with 29% dur- nationally representative samples. None of these epidemio-
ing partnered sex (the corresponding figures for men were logical surveys assessed the prevalence of ‘‘lifelong’’ vs.
80% and 75%). ‘‘acquired’’ orgasmic problems, but of orgasmic ‘‘problems’’
One interesting gender difference is that in clinical situa- or ‘‘anorgasmia.’’ Both the method of assessment and the
tions women rarely complain of reaching orgasm too quickly. time periods assessed differed across studies and not sur-
Reflecting this, there has never been a DSM diagnostic prisingly, the prevalence estimates of orgasm difficulties also
category of ‘‘premature orgasm’’ in women equivalent to varied widely. Reviewing the evidence from European
‘‘premature ejaculation’’ in men. Interestingly, however, data studies, Fugl-Meyer and Fugl-Meyer (2006) concluded,
from two large-scale surveys indicated that between 6 and ‘‘…the prevalence of orgasmic dysfunction appears to vary
15% of women (depending on age) reported that they came to so widely that at the moment there is no conclusive evidence’’
orgasm too quickly (Laumann, Paik, & Rosen, 1999; Rich- (p. 35). Although it may not be possible to establish accurate
ters, Grulich, de Visser, Smith, & Rissel, 2003). It is possible prevalence rates for FOD, there are a number of important
that the survey questions used in these two studies (which aspects related to prevalence and etiology that can be ad-
were similar) were misinterpreted by the female respondents. dressed in large-scale surveys (e.g., possible predictors
Further research is needed to establish whether reaching or- of reported orgasm problems), and these will be discussed
gasm too quickly is a significant problem for women. further below.
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260
Table 3 Prevalence of orgasm problems in selected epidemiological studies
123
Study N of women Country Age Method of assessment Time period Prevalence
Bancroft et al. (2003b) 987; all in heterosexual relationships United 20–65 Computer-assisted telephone Previous month Orgasm during sexual activity with
States interviewing partner (% of occasions)
None: 9.7%
\25: 11.4%
25–50: 23.1%
51–75: 20.1%
[75: 35.7%
Laumann et al. (1999) 1,749; all sexually active over last 12 United 18–59 Face-to-face interview Several months or more Unable to experience orgasm: 25.7%
months States during past 12 months
Lindal and Stefansson 421 Iceland 55–57 Face-to-face interview; Diagnostic Lifetime prevalence Inhibited orgasm (DSM-III criteria):
(1993) Interview Schedule (DIS-III-A) 3.5%
Lindau et al. (2007) 479 United 57–85 Face-to-face interview and self-report Several months or more Unable to experience orgasm: 34%
States questionnaire during past 12 months
Mercer et al. (2003) 4,826; all had at least 1 heterosexual Britain 16–44 Computer-assisted self-interview Past 12 months Unable to experience orgasm:
partner in last 12 months Lasted at least 1 month: 14.4%
Lasted at least 6 months: 3.7%
Najman, Dunne, Boyle, 908 Australia 18–59 Telephone interview Several months in the past Trouble reaching orgasm: 21–30%
Cook, and Purdie (2003) 12 months (depending on age)
Oberg et al. (2004) 1,056, all sexually active during last Sweden 18–65 Structured face-to-face Past 12 months Difficulties reaching orgasm:
12 months interview ? questionnaires Manifest: 22%; Mild: 60%
Richters et al. (2003) 9,134 Australia 16–59 Computer-assisted telephone interview At least 1 month in the past Unable to experience orgasm: 28.6%
12 months
Spira, Bajos, and The ACSF 1,137 France 18–69 Telephone interview Lifetime Unable to experience orgasm:
Group (1994) Often: 11%
Sometimes: 21%
Ventegodt (1998) 753 Denmark 18–88 Postal questionnaire Current experience Unable to experience orgasm: 6.8%
Witting et al. (2008) 5,463 Finland 18–49 Questionnaires (FSFI ? FSDS) Past month Problems with orgasm (met FSFI
cut-off score of 3.75): 31%;
Met FSFI cut-off and reported
distress: 16%
Note: manifest = ‘‘quite often’’, ‘‘nearly all the time’’, and ‘‘all the time’’; mild = ‘‘hardly ever’’ and ‘‘quite rarely’’
FSFI Female Sexual Function Index (Rosen et al., 2000), FSDS Female Sexual Distress Scale (Derogatis et al., 2002)
Arch Sex Behav (2010) 39:256–270
Arch Sex Behav (2010) 39:256–270 261
Few surveys assessing prevalence of sexual problems satisfaction, in more ‘‘male-centered’’ countries, gender
have used psychometrically validated instruments. It is note- differences in sexual satisfaction were more marked than in
worthy here that the only study listed in Table 3 that used a ‘‘gender-equal’’ societies, although in all countries women
structured psychiatric interview (Lindal & Stefansson, 1993) had lower ratings of subjective sexual well-being compared
reported much lower estimates of anorgasmia (3.5%) than the to men.
other studies. Hayes, Dennerstein, Bennett, and Fairley
(2008) found that the use of simple, non-validated questions Association Between Orgasmic Problems and Distress
(compared with validated, multi-item instruments) resulted
in higher estimates for all female sexual disorders. Although early surveys rarely assessed reported distress
Although assessed in only a small number of studies, the about sexual problems, in recent years researchers have
duration of sexual problems and/or the recall period also increasingly incorporated questions about personal or inter-
clearly affects prevalence rates of orgasmic difficulties. personal distress into surveys (e.g., Bancroft et al., 2003b;
Hayes et al. (2008) found that changing recall from ‘‘previous Hayes et al., 2008; King, Holt, & Nazareth, 2007; Oberg et al.,
month’’ to ‘‘one month or more in the previous year’’ in- 2004; Shifren et al., 2008; Witting et al., 2008). There have
creased prevalence rates for all female sexual disorders. In also been self-report measures developed to assess sexual
the UK National Survey of Sexual Attitudes and Lifestyles, distress e.g., the Female Sexual Distress Scale (FSDS)
Mercer et al. (2003) compared prevalence rates for sexual (Derogatis, Rosen, Leiblum, Burnett, & Heiman, 2002) and
problems reported as lasting at least 1 month in the past year the Sexual Satisfaction Scale for Women (SSS-W) (Meston
(referred to here as ‘‘short-term’’) with those lasting at least 6 & Trapnell, 2005), which includes a subscale measuring
months in the last year (‘‘persistent problems’’). Although distress.
14.4% of women reported short-term difficulties in experi- A consistent finding in the literature has been that only a
encing orgasm, only 3.7% had persistent orgasm problems. proportion of women experiencing orgasm difficulties also
As Table 3 indicates, few surveys have assessed orgasm report associated distress (King et al., 2007; Oberg et al.,
problems in older women. In a nationally representative U.S. 2004; Shifren et al., 2008; Witting et al., 2008). An early
probability sample of 1,550 women aged 57–85 years, Lindau study by Frank, Anderson, and Rubinstein (1978) found that
et al. (2007) found that, of those women who were sexually although 63% of married women reported arousal or orgasm
active (n = 479), 34% reported inability to climax ‘‘for sev- problems, 85% of this ‘‘problem’’ group said that they were
eral months or more’’ during the previous 12 months. Report- satisfied with their sexual relationship. Oberg et al. (2004)
ing on additional analyses using this dataset, Laumann, Das, reported that only 44% of Swedish women who were cate-
and Waite (2008) highlighted the strong relationships of stress, gorized as having ‘‘manifest’’ orgasm problems (defined as
anxiety, and depression, as well as relationship satisfaction, experiencing orgasm difficulties ‘‘quite often’’ or ‘‘nearly all
with women’s anorgasmia (and with sexual problems in gen- the time’’) perceived these as ‘‘manifestly distressing.’’ In a
eral). In another large, population-based study of U.S. women Finnish survey, Witting et al. (2008) found that while 31% of
aged 40–65 years old, women with ‘‘vulvovaginal atrophy’’ women reported orgasm problems, the proportion of women
were 2.82 times more likely to report orgasm difficulties than reporting both orgasm problems and distress was only 16%.
those without this condition. Vulvovaginal atrophy was char- In a recent U.S. study involving 31,581 women recruited
acterized by one or more of the following symptoms: vaginal through a national research panel (Shifren et al., 2008), the
dryness, itching, irritation, pain on intercourse or bleeding with age-adjusted prevalence of ‘‘low orgasm’’ was 21.8%; the
intercourse, or with urination. prevalence of orgasm problems with associated distress (and
The Global Survey of Sexual Attitudes and Behaviors also of arousal and desire problems with sexually related
(Laumann et al., 2005) used computer-assisted telephone distress) was much lower (3.4–5.8%, depending on age).
interviewing and postal questionnaires to assess sexual Physical health problems and current depression were highly
problems in 9,000 women aged 40–80 years. Although this associated with increased odds of orgasm problems.
study had a number of limitations (e.g., low response rate, Bancroft et al. (2003b) examined heterosexual women’s
differences in recruitment and method of assessment across distress about their sexual relationship and/or their ‘‘own
sites), the findings are of interest because the female res- sexuality.’’ Of those women who did not experience orgasm,
pondents were from 29 countries. The prevalence of ‘‘inabil- 30–50% (depending on age) reported marked distress about
ity to reach orgasm’’ ranged from 17.7% (in Northern Eur- their sexual relationship. An important finding of this study
ope) to 41.2% (in Southeast Asia). Age was not consistently was that physical aspects of sexual response in women
related to the likelihood of orgasm problems. Other factors (including orgasm) were relatively weak predictors of dis-
(e.g., physical health) were significant predictors of orgasm tress about sex, while emotional and relationship ‘‘well-
difficulties in some countries but not in others, underlining being’’ were strong predictors. As the authors concluded, ‘‘In
the importance of cultural factors. Regarding overall sexual general, the predictors of distress about sex did not fit well
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262 Arch Sex Behav (2010) 39:256–270
with the DSM-IV criteria for the diagnosis of sexual dys- problems in the previous year sought help, whereas 31.9% of
function in women’’ (p. 193). women with ‘‘persistent’’ problems (lasting at least 6 months
A recent UK study compared ICD-10 diagnoses of women’s in the past year) sought treatment.
sexual dysfunction with women’s own views of their sexual In considering the literature on the sexual problems for
difficulties (King et al., 2007). The findings suggested a sig- which women and men seek treatment, Bancroft (2009) ob-
nificant discordance between clinical diagnoses and women’s served that men more often complain about problems with
experiences of sexual problems. Regarding orgasmic dys- their genital responses (i.e., erection or ejaculation), whereas
function, 18% of the women met ICD-10 criteria, but only 8% women primarily present with complaints about the sub-
met criteria and also perceived that they had a sexual prob- jective quality of the sexual experience e.g., lack of interest or
lem. An even smaller proportion (5%) met diagnostic criteria pleasure. This issue is very relevant to the DSM-IV classifi-
and reported that their inability to experience orgasm was a cation system for sexual dysfunction, which has largely as-
‘‘somewhat’’ or ‘‘very’’ distressing problem. Women who re- sumed that women and men experience similar sexual
ceived an ICD-10 sexual dysfunction diagnosis and them- difficulties, and which has also focused on genital responses
selves considered that they had a problem were more likely to (lubrication for women and erection for men).
report some homosexual interest. The authors of this study
concluded that ‘‘DSM-IV-TR… misses a significant propor-
tion of women who are distressed by what they regard as sex- Possible Etiological Factors in Orgasmic Dysfunction
ual difficulties but which do not fit a diagnostic classifica-
tion’’ (p. 287). These findings emphasize the importance of Although many possible causes of orgasmic dysfunction
obtaining qualitative data on women’s experiences of their have been proposed, ranging from inadequate tone in the
sexual difficulties. perivaginal muscles (Graber & Kline-Graber, 1979) to anx-
While many studies have found associations between iety and distracting thoughts (Dove & Wiederman, 2000), in
orgasmic responsiveness in women and relationship satis- most cases the etiology remains uncertain (Heiman, 2007).
faction (Mah & Binik, 2001), it is clear that the absence of
orgasm does not mean that a woman cannot have a satisfac- Psychosocial Factors
tory and enjoyable sexual relationship. Wellings, Field,
Johnson, and Wadsworth (1994) found fairly similar per- A wide range of psychological factors, such as anxiety and
centages of women (43.3%) and men (48.7%) agreed with the concerns about pregnancy, can potentially interfere with
statement ‘‘sex without orgasm cannot be really satisfying.’’ women’s ability to reach orgasm. It is clear, however, that
The issue of distress seems likely to be related to the degree to there is considerable variability across individual women in
which orgasm is important to an individual woman. Here how likely they are to be affected by such factors, and we
again research indicates considerable variability; orgasm understand little about the reasons for this variability.
seems to be very important for some women but less Regarding personality factors, in DSM-III (American
important for others (Bancroft, 2009). Psychiatric Association, 1980), ‘‘histrionic traits in women’’
were said to be ‘‘frequently associated’’ with Inhibited Or-
Prevalence of Female Orgasmic Disorder in Clinical gasm. In DSM-III-R (American Psychiatric Association,
Populations 1987), this text was removed. The DSM-IV-TR (American
Psychiatric Association, 2000) text includes this statement:
Although difficult to substantiate, it has been suggested that ‘‘No association has been found between specific patterns of
FOD is less common as a presenting problem than it was personality traits or psychopathology and orgasmic dys-
during the early days of sex therapy (Heiman, 2007). A function in females’’ (p. 505). This accords with the research
number of studies involving clinic populations have identi- evidence; in a review of the literature, Mah and Binik (2001)
fied low sexual interest as the most frequent presenting concluded, ‘‘Overall, associations between female orgasm
problem among women, with orgasmic problems typically response and psychopathological adjustment have not been
cited as the second most common complaint (Catalan, supported’’ (p. 834).
Hawton, & Day, 1990; Hirst, Baggaley, & Watson, 1996; Many studies have investigated the relationship between
Roy, 2004; Warner & Bancroft, 1987). In a study of women female orgasmic problems and socio-demographic factors
attending outpatient gynecology clinics, 29% reported such as age, education, marital status, and religiosity, but
orgasmic problems (Rosen, Taylor, Leiblum, & Bachmann, there have been few consistent findings. The DSM-IV-TR
1993). Among UK women attending their general practitio- text notes: ‘‘Because orgasmic capacity in females increases
ners, a similarly high proportion (23%) reported anorgasmia with age, Female Orgasmic Disorder may be more prevalent
(Read, King, & Watson, 1997). Mercer et al. (2003) found in younger women’’ (p. 505). While younger age has been
that overall, only 21.0% of women reporting any sexual associated with greater likelihood of orgasmic difficulties in
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Arch Sex Behav (2010) 39:256–270 263
some studies (e.g., Hawton, Gath, & Day, 1994; Laumann (2005) compared identical and non-identical twin pairs
et al., 1999), other research has either found no relationship (4,037 women) from the Twins UK register and found that
between age and orgasm problems (Oberg et al., 2004), or has between 34 and 45% of the variation in ability to orgasm
reported the converse i.e., orgasm problems more common in could be explained by underlying genetic variation. Recruit-
older women (Richters et al., 2003). Variables that have been ing women from the Australian Twin Registry, Dawood et al.
more consistently related to experience of orgasmic diffi- (2005) reported that genetic influences accounted for approx-
culties (and indeed to most sexual problems in women) have imately 31% of the variance of frequency of orgasm during
been poor physical and mental health (Bancroft et al., 2003b; sexual intercourse, and 51% of the variance of frequency of
Laumann et al., 1999; Richters et al., 2003) and relationship orgasm during masturbation. More recently, Harris et al.
difficulties/partner variables (Dennerstein, Lehert, Burger, & (2008) investigated personality factors and their association
Dudley, 1999; Kelly, Strassberg, & Turner, 2004). with female coital ‘‘orgasmic infrequency’’ in a sample of
2,632 women from the same UK twin register. Introversion,
Physiological Factors emotional instability, and ‘‘not being open to new experi-
ences’’ were associated with orgasmic infrequency. While
Many physiological factors may influence a woman’s ability these results are intriguing, the authors themselves acknowl-
to experience orgasm, including illnesses, neurological con- edged that their assessment of orgasm was quite limited and
ditions, and some medications (Basson & Weijmar Schultz, these studies require replication. Another twin study involv-
2007). West, Vinikoor, and Zolhoun (2004) reviewed the ing 6,446 female twins and 1,994 siblings aged 18–49 years
evidence on orgasmic dysfunction related to reproductive explored genetic and environmental influences on sexual
factors, such as pregnancy and hysterectomy. Although some problem reporting; individual differences in all sexual prob-
studies have reported increased orgasm problems after lems assessed (desire, arousal, lubrication, orgasm, pain, and
menopause, this has not been a consistent finding. It has been satisfaction) were chiefly due to non-shared (individual-
difficult to disentangle the effects of menopause from those of specific) environmental influences; genetic influences were
age, partner factors, and psychosocial factors. In one popu- ‘‘modest but significant’’ (Witting et al., 2008, p. 115).
lation-based sample of American women, menopausal status
was not associated with likelihood of orgasm difficulties
(Avis, Stellato, Crawford, Johannes, & Longcope, 2000).
Studies that have investigated sexual functioning fol- Critiques of DSM-IV-TR Criteria for Female Orgasmic
lowing different types of hysterectomy (e.g., total abdominal Disorder
vs. supracervical) have not found any differences in outcome
related to type of procedure; overall, the majority of women The DSM-IV classification of sexual disorders in women has
experienced either no change, or an improvement, in sexual received significant criticism (Boyle, 1994; Irvine, 1990;
functioning, including frequency of orgasm, following hys- Tiefer, 1991, 2001). Some authors have suggested revised
terectomy (Kim, Lee, & Lee, 2003; Roussis, Waltrous, Kerr, definitions for sexual disorders, while retaining the basic
Robertazzi, & Cabbad, 2004). structure of the DSM system, i.e., desire, arousal, and orgasm,
For many years little was known about possible sexual side and pain disorders (e.g., Basson et al., 2000, 2003). Others
effects of medications in women, although recently this has have argued for dismantling the DSM system and replacing it
changed, with particular attention to the effects of antide- with a new and more women-centered classification (Tiefer,
pressants (Graham & Bancroft, 2009). Delayed orgasm is the 2001). These various critiques will now be reviewed.
mostly commonly reported side effect of selective serotonin In 2000, the American Foundation for Urologic Disease
re-uptake inhibitors (SSRIs) in both men and women, affect- (AFUD) convened a conference panel, comprising 19 experts
ing between 30 and 60% of those using these medications (for who reviewed the DSM-IV criteria for female sexual dys-
reviews, see Montgomery, Baldwin, & Riley, 2002 and function. The Report of the International Consensus Devel-
Rosen, Lane, & Menza, 1999). Rosen et al. (1999) concluded opment Conference on Female Sexual Dysfunction (Basson
that women taking SSRIs experienced orgasm-related side et al., 2000) suggested various revisions to the diagnostic
effects more often than men. One placebo-controlled study criteria but preserved DSM categories ‘‘to maintain conti-
reported that sildenafil treatment improved symptoms of nuity in research and clinical practice’’ (p. 890). For FOD,
delayed orgasm in women (Nurnberg et al., 2008). the addition of ‘‘difficulty’’ in attaining orgasm (as well as pos-
Several studies have explored the role of genetic influ- sible delay or absence of orgasm) to Criterion A was the only
ences on female orgasmic function in non-clinical samples of revision suggested. Some researchers and clinicians were
women (Dawood, Kirk, Bailey, Andrews, & Martin, 2005; critical of the Consensus Committee process and the fact that
Dunn, Cherkas, & Spector, 2005; Harris, Cherkas, Kato, only minor revisions were advocated, arguing that this re-
Spector, & Heiman, 2008; Witting et al., 2009). Dunn et al. flected an inability to ‘‘break out of the DSM-IV confines and
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264 Arch Sex Behav (2010) 39:256–270
develop a new and possibly more useful classification sys- Disorder, in that it suggests a possible ‘‘merging’’ of the
tem’’ (Bancroft, Graham, & McCord, 2001, p. 98). different categories of desire, arousal, and orgasm. Basson’s
In 2002–2003, another AFUD-sponsored international suggestion is consistent with Hartmann, Heiser, Ruffer-
multidisciplinary group was convened to review definitions Hesse, and Kloth’s (2002) argument that female sexual prob-
of women’s sexual dysfunction, including those proposed by lems should not be conceptualized as discrete phase disor-
Basson et al. (2000) a few years earlier, which were now ders, but instead as ‘‘a global inhibition of sexual response’’
considered ‘‘unsatisfactory.’’ A number of recommendations (p. 79).
for ‘‘expansion and revision’’ of definitions were provided Unlike the above recommendations for revising specific
(Basson et al., 2003). Once again, the basic structure of the DSM diagnostic criteria, the New View of Women’s Sexual
DSM was retained. Regarding FOD, there were only two Problems offered an alternative classification system of wo-
revisions: the first was the addition of a reduction in orgasmic men’s sexual problems (Kaschak & Tiefer, 2001). The New
intensity as part of the criteria, and the second involved a View was written by a group of clinicians and social scientists
change in sentence structure to emphasize the fact that high or (The Working Group for a New View of Women’s Sexual
‘‘adequate’’ sexual arousal was a criterion for the diagnosis of Problems) critical of the DSM taxonomy of sexual disorders.
FOD. The revised definition for ‘‘Women’s Orgasmic Dis- Their primary criticisms of the DSM were that it ignored
order’’ was: ‘‘Despite the self-report of high sexual arousal/ gender differences in sexuality, relational aspects of women’s
excitement, there is either lack of orgasm, markedly dimin- sexuality, and individual differences in sexual experience
ished intensity of orgasmic sensations, or marked delay of among women. The New View of Women’s Sexual Problems
orgasm from any kind of stimulation’’ (Basson et al., 2003, p. (Kaschak & Tiefer, 2001) provided a ‘‘woman-centered’’
226). The justification for the inclusion of a reduction in definition of sexual problems as ‘‘discontent or dissatisfaction
intensity of orgasm was that clinically it is not uncommon to with any emotional, physical, or relational aspect of sexual
find that women with some types of neurological disease or experience’’ (p. 5). Unlike the DSM, the New View classifi-
undergoing chemotherapy report reduced orgasmic intensity cation system is not based on symptom criteria, but is instead
(Basson, 2002). The emphasis on ‘‘self-report of high sexual organized around four possible categories of causes: socio-
arousal/excitement’’ was added because it was argued that cultural, political, or economic factors; partner and relation-
researchers had often ignored the requirement that women ship factors; psychological factors; and medical factors.
diagnosed with FOD must have high or ‘‘adequate’’ arousal. Nicholls (2008) examined the degree to which women’s
Although Basson et al. (2003) stated that ‘‘a DSM-IV diag- accounts of their sexual difficulties accorded with the New
nosis of orgasmic disorder precludes one of arousal disorder’’ View framework. Although this was a small study, involving
(p. 226), as discussed above, the DSM text states that FOD only 49 women, the findings did support the utility of the New
may also occur in association with other sexual dysfunctions, View perspective. Although to date this has been the only
including Female Sexual Arousal Disorder (p. 506). empirical study that has evaluated the New View classifica-
In clinical settings, women with lifelong FOD may often tion system, other research provides indirect support for some
also have arousal difficulties although they generally focus of its basic tenets (e.g., that there is no unitary phenomenon of
on, and seek treatment because of, the lack of orgasm (Bas- ‘‘dysfunction’’ and that there is substantial variability in wo-
son, 2002). In support of this is research by Andersen and men’s experiences). For example, a study by Sand and Fisher
Cyranowski (1995) on sexual arousal in women diagnosed (2007) challenged the assumption that there is an underlying
with lifelong FOD. These researchers found that women ‘‘model’’ of sexual response that is uniform across women.
presenting for treatment with orgasmic problems varied These researchers asked a community sample of nurses which
widely in their experience of sexual arousal. They concluded of three different models of sexual response—Masters and
that a number of different ‘‘subtypes’’ of orgasmic dysfunc- Johnson’s (1966), Kaplan’s (1974), and Basson’s (2000)—
tion likely exist and that the proportion of anorgasmic women best represented their own experience. Approximately equal
presenting for treatment who would report unimpaired sexual proportions of women endorsed each of these three models,
arousal (i.e., not meeting DSM-IV criteria for Female Sexual highlighting the diversity of women’s sexual responses.
Arousal Disorder) would likely be very low. The above section has outlined some of the critiques of the
Basson (2002) suggested that we reconsider how we de- DSM-IV diagnostic criteria put forward by clinicians and
fine orgasmic ‘‘dysfunction,’’ commenting, ‘‘Given that un- researchers. Before discussing the specifics of the DSM-IV-
like the male response, a woman’s orgasm often is not a one- TR criteria for FOD in more detail, and making some rec-
peak event but is a component of her arousal…it would seem ommendations for change, two key challenges for the clas-
helpful to define dysfunctional orgasmic release in terms of sification of sexual dysfunction will be discussed, with a
arousal itself’’ (p. 297) (italics added). This issue is one that is particular focus on how they are relevant to orgasmic diffi-
relevant to the DSM definition of Female Sexual Arousal culties in women. These issues are: (1) How do we best avoid
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Arch Sex Behav (2010) 39:256–270 265
pathologizing normal variation? and (2) How do we effec- specifiers’’; specifiers are typically used to ‘‘describe the
tively acknowledge the relational context of sexual prob- course of the disorder or to highlight prominent symptoms’’
lems? (Mitchell & Graham, 2007). or to ‘‘indicate associated behavioral patterns of clinical inter-
As highlighted in this review, there is substantial vari- est’’ (p. 364). With regard to orgasmic disorder, these might
ability in the capacity for, and experience of, orgasm across include reference to information about the partner of a wo-
women. Women also differ greatly in how important orgasm man presenting with orgasmic difficulties (e.g., whether they
is to their sexual satisfaction. Given this variability, what have other problems with sexual functioning, are lacking
strategies might be proposed to avoid pathologizing this knowledge about sexual techniques, etc.). These factors could
normal variation in orgasm? have major effects on a woman’s ability to experience or-
One strategy that has been adopted is to include a distress gasm and this type of information would have clear impli-
criterion as a necessary, but not sufficient, criterion for diag- cations for treatment.
nosing dysfunction. ‘‘Marked distress or interpersonal diffi- Specific aspects of the DSM-IV-TR criteria for FOD, and
culty’’ is currently an essential criterion for any DSM diag- the accompanying text, will now be considered, and recom-
nosis of sexual dysfunction. As discussed above, many stud- mendations made for possible revision.
ies have found markedly lower prevalence rates for sexual
disorders, including orgasmic dysfunction, when distress has
been assessed. However, given the strong messages from the Recommendations
media about the importance of orgasm, as well as possible
expectations/pressure from sexual partners, distress may be DSM-IV-TR Text on Female Orgasmic Disorder
engendered even when women experience short-term and/or
mild difficulties with orgasm. There are also issues related to The description of orgasm in the DSM-IV-TR text predom-
the definition/measurement of ‘‘marked distress or interper- inantly focuses on the physiological changes that (may)
sonal difficulty.’’ Utilizing a dimensional assessment of dis- accompany orgasm in women. The recommendation made
tress might be helpful in this regard (Widiger & Samuel, here is to ‘‘de-emphasize’’ these physiological aspects of
2005). orgasm, for two reasons: firstly, as discussed earlier, the text
Another option is to specify more precise criteria for suggests that physiological changes such as contractions of
severity and/or duration of problems and here there have been the anal sphincter invariably occur, whereas research has
some specific recommendations put forward. Balon and col- established that this is not the case (Bohlen et al., 1982).
leagues (Balon, 2008; Balon, Segraves, & Clayton, 2007; Subjective aspects of orgasm should be better highlighted, as
Segraves, Balon, & Clayton, 2007) have pointed out that DSM these are the reasons why women seek treatment for orgasm
criteria for a number of other disorders include duration of problems (i.e., not because they do not experience contrac-
symptoms. These authors proposed that a duration criterion of tions of the anal sphincter) and also because assessment of
6 months be added to the diagnostic criteria for all sexual physiological changes that occur during orgasm is not fea-
disorders. Citing Oberg et al.’s (2004) finding that differ- sible in clinical practice. Secondly, it should be emphasized
entiating between mild (defined as ‘‘hardly ever’’ or ‘‘quite that both the physiological and the subjective changes
rarely’’) vs. ‘‘manifest’’ (‘‘quite often,’’ ‘‘nearly all the time,’’ experienced during orgasm are extremely variable across
or ‘‘all the time’’) symptoms resulted in markedly lower prev- women and on different occasions.
alence rates of sexual disorders, Balon et al. (2007) also sug-
gested that more specific severity criteria be considered. DSM-IV-TR Diagnostic Criteria for Female Orgasmic
Although clearly more research is needed on the pre- Disorder
cise severity and duration criteria that should be adopted for
DSM-V, it is recommended here that duration and/or severity Criterion A for FOD requires ‘‘Persistent or recurrent delay
criteria be added as part of the symptom criteria for FOD. in, or absence of, orgasm following a normal excitement
Turning to the relational context of orgasmic problems, as phase.’’ It is recommended that, consistent with suggestions
discussed above, one criticism of the DSM classification of by Balon et al. (2007) and Segraves et al. (2007), specific
sexual disorders is that it does not sufficiently acknowledge criteria related to duration and severity be added. This should
the relational context of sexual problems (Kaschak & Tiefer, help to differentiate more persistent sexual problems, which
2001; Mitchell & Graham, 2007). Although the DSM does are often (although not always) associated with significant
note relational processes in the V codes, some have argued distress, from short-term changes in sexual functioning,
that these have been poorly described and have not proven which may actually be ‘‘adaptive’’ reactions in some situa-
useful for clinical or research purposes (Beach, Wamboldt, tions (Bancroft et al., 2003b).
Kaslow, Heyman, & Reiss, 2006). Beach et al. (2006) sug- The second recommendation is to delete the reference
gested that another option might be to develop ‘‘relationship to ‘‘a normal excitement phase.’’ As reviewed earlier, the
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266 Arch Sex Behav (2010) 39:256–270
requirement that there be a ‘‘normal excitement phase’’ seems direct physiological effects of a substance (e.g., a drug of
to have engendered considerable confusion. While some re- abuse, a medication), or a general medical condition.’’ It is
searchers and clinicians (e.g., Basson et al., 2003) have erro- questionable whether it can ever be established that a sexual
neously interpreted this to mean that a diagnosis of Female dysfunction is due ‘‘exclusively’’ to the effects of a medica-
Arousal Disorder precludes a diagnosis of FOD, the DSM-IV- tion or a physical illness. Much of the early research on eti-
TR text includes a clear statement that both diagnoses can be ological factors relevant to orgasmic dysfunction focused on
made. Secondly, there is some evidence (Andersen & Cyra- the individual woman, with relationship and socio-cultural
nowski, 1995) that the proportion of women who are anorgas- aspects largely neglected. In recent years this focus has
mic and who also report a ‘‘normal sexual excitement phase’’ shifted, with recognition that partner and relationship factors
may be very small. Lastly, the phrase ‘‘a normal excitement are of crucial importance in sexual dysfunction (Byers &
phase’’ suggests that women’s experiences of sexual arousal Grenier, 2003; Dennerstein, Lehert, & Burger, 2005; Fisher,
and orgasm are uniform whereas, as discussed above, there is Rosen, Eardley, Sand, & Goldstein, 2005; King et al., 2007;
substantial variability, which should be acknowledged in the Oberg et al., 2004). It is recommended that Criterion C be
DSM text. revised to acknowledge the fact that in many cases of
Also included in Criterion A is the statement that the orgasmic problems in women, the causes of orgasmic dis-
diagnosis of FOD ‘‘should be based on the clinician’s judg- orders are multifactorial, or cannot be determined.
ment that the woman’s orgasmic capacity is less than would
be reasonable for her age, sexual experience, and the ade- DSM-IV-TR Diagnostic Subtypes
quacy of sexual stimulation that she receives.’’ As reviewed
earlier, the evidence relating to associations between age and As outlined above, DSM-IV-TR provides subtypes to indi-
orgasmic difficulties is somewhat inconsistent. However, cate ‘‘the onset, context, and etiological factors’’ (p. 494)
this statement does reflect the fact that a number of factors associated with a particular sexual dysfunction. These sub-
need to be considered before a diagnosis of FOD can be made. types are: Lifelong vs. Acquired; Generalized vs. Situational;
It is recommended that greater emphasis be placed on the rela- and Due to Psychological Factors vs. Due to Combined
tional aspects of orgasmic problems. There is good evidence Factors.
that women’s distress about sexual functioning is signifi- For both clinical and research purposes, the distinction
cantly associated with relationship problems (King et al., between ‘‘lifelong’’ and ‘‘acquired’’ orgasmic problems
2007; Witting et al., 2008). Additional text might be added seems useful. A key issue in the clinical context is to assess an
here on the importance of carefully assessing partner variables individual woman’s capacity for orgasm and whether she has
(e.g., partner’s sexual functioning) and relationship function- been able to experience orgasm in the past. The recommen-
ing in clinical assessment of women presenting with orgas- dation here is that this distinction be retained. It should be
mic difficulties. noted, however, that the terminology used in the literature to
Criterion B requires that ‘‘the disturbance cause marked refer to this distinction has been inconsistent, with some
distress or interpersonal difficulty.’’ Issues regarding the dis- authors (e.g., Heiman, 2007) using the term ‘‘primary anor-
tress requirement have been discussed earlier. From a clinical gasmia’’ rather than ‘‘lifelong anorgasmia’’ to refer to women
perspective, women who are not distressed by an inability to who have never been able to experience orgasm.
reach orgasm are unlikely to seek treatment and conse- The ‘‘Generalized’’ vs. ‘‘Situational’’ subtypes have some
quently, would not be given a diagnosis. However, with re- clinical utility. In clinical situations, differentiating between
gard to research, it seems important to assess the presence of women who lack the capacity for experiencing orgasm, and
distress, as the studies reviewed earlier have consistently those who have some degree of capacity, but require specific
documented much higher prevalence rates of orgasmic and sufficiently intense (or highly specific) stimulation, to
‘‘dysfunction’’ when distress is not taken into account. This experience orgasm, seems important. This distinction can be
might be better done using dimensional criteria, rather than helpful in guiding decisions about formulation and treatment.
(as at present) a categorical assessment of whether distress is It is important, however, that ‘‘situational’’ is not misinter-
present or absent (Regier, 2008; Widiger & Samuel, 2005), preted to mean experience of orgasm with clitoral stimulation
and assessing distress as a ‘‘specifier,’’ rather than part of the but not during vaginal intercourse. In the revised text on FOD,
symptom criteria. The degree of distress that women report it should be made explicit that women who experience or-
from being unable to experience orgasm is extremely vari- gasm during clitoral stimulation, but not during vaginal-
able and assessment of this distress is important for both penile intercourse, do not meet criteria for ‘‘orgasmic disorder.’’
clinical and research purposes. The final subtypes, ‘‘Due to Psychological Factors’’ and
Criterion C requires that ‘‘The orgasmic dysfunction is not ‘‘Due to Combined Factors,’’ are of little clinical or research
better accounted for by another Axis I disorder (except an- relevance. In practice it is often very difficult to establish
other Sexual Dysfunction) and is not due exclusively to the causation of orgasmic problems with any certainty (Heiman,
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Arch Sex Behav (2010) 39:256–270 267
Table 4 Proposed revision to DSM-IV criteria for Female Orgasmic we have little empirical data on the prevalence of lifelong vs.
Disorder acquired orgasmic problems.
A. At least one of the two following symptoms: Basson (2002) recommended inclusion of possible changes
1. Delay in, or absence of, orgasm; in orgasm intensity to diagnostic criteria for FOD. Apart from
2. Markedly reduced intensity of orgasmic sensations. research on the effects of physical illness or medication on
B. Symptom(s) must have been present for at least 6 months and be orgasmic functioning, there appears to have been little atten-
experienced on 75% or more of occasions of sexual activity. tion to this aspect of orgasm. It seems important to acknowl-
C. The problem causes marked distress or interpersonal difficulty. edge that orgasm is not an ‘‘all-or-nothing’’ phenomenon, and
Specify if: Lifelong vs. Acquired that diminished intensity of orgasm may be a problem for some
Specify if: Generalized vs. Situational women. On the other hand, we should avoid pathologizing
Specify if: with concomitant problems in sexual interest/sexual arousal normal variation in the experience of orgasm. A dimensional
Dimensional Specifiers: approach would seem to be the best option to assess the
(1) Partner factors (partner’s sexual problems, partner’s health ‘‘quality’’ of orgasm, although empirical evidence that orgasm
status) intensity can be measured in a reliable way is needed.
(2) Relationship factors (e.g., poor communication, relationship One important ‘‘gap’’ in previous research is the lack of
discord, discrepancies in desire for sexual activity) information on orgasmic difficulties experienced by women
(3) Individual vulnerability factors (e.g., depression or anxiety, poor who self-identify as lesbian or bisexual. Most previous
body image, history of abuse experiences)
studies of prevalence rates of FOD, for example, have in-
(4) Cultural/religious factors (e.g., inhibitions related to prohibitions
cluded only heterosexual women. Future studies should
against sexual activity)
endeavour to include women of different sexual orientations
(5) Medical factors (e.g., illness/medication)
in studies on orgasm. Lastly, much more research is needed
on women’s experience of orgasm and reported orgasmic
2007) and, as discussed above, there is increasing recognition problems in different cultures.
that both psychological and physical factors are often
implicated in the causation of sexual dysfunction (Basson & Acknowledgments The author is a member of the DSM-V Work-
group on Sexual and Gender Identity Disorders. I wish to acknowl-
Weijmar Schultz, 2007). The recommendation made here is
edge the valuable input I received from members of my Workgroup
to consider removing these subtypes from the FOD category. (Yitzchak Binik, Lori A. Brotto, R. Taylor Segraves) and Kenneth J.
Table 4 contains proposed diagnostic criteria for orgas- Zucker. Feedback from DSM-V Advisors Richard Balon, John Ban-
mic disorder in women. croft, Rosemary Basson, Marta Meana, and Leslie Schover is greatly
appreciated. Reprinted with permission from the Diagnostic and Sta-
tistical Manual of Mental Disorders V Workgroup Reports (Copyright
2009), American Psychiatric Association.
Further Research
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DOI 10.1007/s10508-009-9534-2
ORIGINAL PAPER
The DSM Diagnostic Criteria for Sexual Aversion Disorder

Lori A. Brotto

Abstract Sexual Aversion Disorder (SAD) is one of two Sex- professional attention, and students in the field are hard put to
ual Desire Disorders in the Diagnostic and Statistical Manual of find literature on this topic’’ (p. 3). The state of the science some
Mental Disorders (DSM) and is defined as a ‘‘persistent or 20-plus years later has not changed much and there are still little
recurrent extreme aversion to, and avoidance of, all or almost empirical data on Sexual Aversion Disorder (SAD). SAD is one
all, genital sexual contact with a sexual partner’’ which causes of two Sexual Desire Disorders in the Diagnostic and Statistical
distress or interpersonal difficulty. This paper reviews the short Manual of Mental Disorders (DSM-IV-TR; American Psychi-
history of the diagnosis of SAD as well as the existing literature atric Association, 2000) (the other one being Hypoactive Sexual
on its prevalence and etiology. Kaplan (1987) emphasized the Desire Disorder (HSDD)), and the most recent addition to the
phobic qualities of individuals with SAD who are highly list of Sexual Dysfunctions in the DSM (American Psychiatric
avoidant of all forms of sexual contact. Much has also been Association, 1987). Relative to the research done on HSDD,
written about the overlap between SAD and panic states, and the much less is known about the prevalence, etiology, and treat-
more obvious similarities between SAD and anxiety as opposed ment of SAD.
to sexual desire are described. There has been very little new
published data on SAD since the publication of DSM-IV and the
precise prevalence remains unknown. This paper critiques the Diagnosis
placement of SAD as a Sexual Dysfunction and argues that it
might more appropriately be placed within the Specific Phobia The original diagnostic criteria for SAD (302.79) required a
grouping as an Anxiety Disorder. ‘‘persistent or recurrent extreme aversion to, and avoidance
of, all or almost all, genital sexual contact with a sexual part-
Keywords Sexual Aversion Disorder Sexual phobia ner’’ and that this symptom did not occur ‘‘during the course
Sexual avoidance DSM-IV-TR DSM-V of another Axis I disorder (other than a Sexual Dysfunction),
such as Major Depression’’ (American Psychiatric Associa-
tion, 1987, p. 293).
In the DSM-IV-TR (American Psychiatric Association,
Introduction 2000), Criterion A did not change from that listed in the DSM-
III-R. The only addition to the diagnostic criteria was Criterion
In the book, Sexual Aversion, Sexual Phobias, and Panic Dis- B–that the disturbance cause marked distress or interpersonal
order, published in the same year that DSM-III-R (American difficulty (Table 1). The DSM-IV-TR text indicates that anx-
Psychiatric Association, 1987) was released, Kaplan (1987) re- iety, fear, or disgust when confronted with a sexual opportunity
marked that ‘‘sexual panic states have received surprisingly little are features of SAD. Moreover, the scope of the sexual stimuli
producing the aversion can range from a specific aspect of the
sexual encounter (e.g., genital secretions) to any and all sexual
L. A. Brotto (&)
stimuli (including kissing, touching, and hugging). The text
Department of Obstetrics and Gynaecology, University of British
Columbia, 2775 Laurel Street, Vancouver, BC V5Z 1M9, Canada goes on to describe symptoms of anxiety (e.g., panic attacks)
e-mail: [email protected] and avoidance behavior as signs of severe SAD.
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272 Arch Sex Behav (2010) 39:271–277
Table 1 DSM-IV-TR diagnostic criteria for Sexual Aversion Disorder focuses on the affective aspects and not on the behavioral aspects
(302.79) (as the latter is captured by ‘‘and avoidance’’).
A. Persistent or recurrent extreme aversion to, and avoidance of, all (or It is likely (although this cannot be verified due to the unavail-
almost all) genital sexual contact with a sexual partner ability of DSM-III-R Sourcebooks) that the empirical justifica-
B. The disturbance causes marked distress or interpersonal difficulty tion for including SAD as a new disorder in DSM-III-R stem-
C. The sexual dysfunction is not better accounted for by another Axis I med from Kaplan’s own patients and observations. Kaplan
disorder (except another Sexual Dysfunction) (1987) reported on the characteristics of 373 patients with sexual
Specify type avoidance who were seen at the Human Sexuality Program of
Lifelong type the Payne Whitney Clinic as well as a private clinic between
Acquired type 1976 and 1986. Kaplan found that 9% of those who avoided sex
Specify type also met criteria for Panic Disorder and, as such, suggested that
Generalized type pharmacotherapy for the Panic Disorder would improve the
Situational type sexual aversion. The proportion of those with Panic Disorder
Specify was even higher (25%) among those individuals who avoided
Due to psychological factors sex and also had a phobia of sex. Another 25% of those with
Due to combined factors phobic avoidance of sex experienced emotional signs and symp-
toms of Panic Disorder but did not meet full criteria.
It is noteworthy that Kaplan (1987) originally described SAD
as a sexual phobia. A considerable portion of Kaplan’s book was
Sexual aversion was described by Kaplan as being persistent spent on describing the panic experienced by these individuals
and irrational as well as ego-dystonic, with the phobic avoidance and describing therapeutic approaches to phobias (in general) as
causing significant distress to the individual. She also indicated well as Panic Disorder. Kaplan (1988) noted that individuals with
that it may or may not be co-morbid with other sexual dys- Panic Disorder were particularly prone to SAD because of their
functions. Kaplan described total and situational forms of sexual personality traits of separation anxiety, rejection sensitivity, and
aversion: total aversion involved any and all erotic sensations, overreaction to criticism from significant others such as lovers.
feelings, thoughts, and opportunities whereas situational was The placement of SAD as a Sexual Dysfunction as opposed to
limited to a specific aspect of sex (e.g., genitalia, being pene- a Specific Phobia at the time seems to have been related to the
trated, fantasies, orgasm, oral sex, etc.). Kaplan noted an inter- type of stimulus responsible for the phobic reaction (i.e., a sexual
esting feature of individuals with situational sexual aversion in stimulus). However, the other Specific Phobias (then classed as
that they could enjoy many aspects of sexual activity as long as Simple Phobias) were not similarly categorized according to the
avoidance of their circumscribed phobic stimulus could be type of stimulus that provoked symptoms (e.g., public speaking
maintained. Kaplan also described enormous variability across phobia is not characterized as an Interpersonal Disorder, and fear
individuals with sexual aversion in their willingness to be sex- of heights is not placed in a different category of related syn-
ually active, with some who were able to push past their reluc- dromes). Kaplan (1987) presented the DSM-III criteria for Sim-
tance of sex and, once engaging in sexual activity, to experience ple Phobia (300.29) and pointed out the similarity to the proposed
satisfaction. Others, however, were more severely phobic such DSM-III-R criteria for SAD, stating: ‘‘It is not clear to me whether
that they could not feel any erotic sensations. Some of these indi- sexual phobia and aversion are two discrete disorders…or whe-
viduals also experience panic attacks (‘‘discrete period of intense ther aversion is simply a form of sexual panic with especially
apprehension, fearfulness, or terror, often associated with feelings intense autonomic reactions. At this time, I tend to conceptualize
of impending doom’’ [American Psychiatric Association, 2000] sexual aversion and phobic avoidance of sex as two clinical
with symptoms of autonomic activation). What makes sexual variations of sexual panic states’’ (p. 11). The DSM-IV-TR text
aversion so distressing is that, unlike other phobias (e.g., snakes, on the Differential Diagnosis section of SAD indicates that
heights), it is possible to avoid the phobic stimulus with little ‘‘Although sexual aversion may technically meet criteria for
interference in the individual’s life. However, with sexual pho- Specific Phobia, this additional diagnosis is not given.’’ The ratio-
bias, Kaplan noted that ‘‘its avoidance can be profoundly destruc- nale for why this was the case was not provided and there was no
tive’’ given that sexuality is a core feature of human existence. information in the DSM-IV Sourcebook justifying this disclaimer.
Aversion itself is not actually defined in the DSM-IV (or DSM- On the other hand, the Differential Diagnosis section of Specific
III-R). In other contexts, it is conceptualized as an emotion (e.g., Phobia makes no mention of SAD.
feelings of repugnance or extreme dislike) (Toronchuk & Ellis, Despite the apparent similarities between sexual aversion
2007). Other aversions (e.g., conditioned taste aversion) may em- and Specific Phobia, Janata and Kingsberg (2005) noted that a
phasize the behavioral correlates of aversion and not the emotional critical difference between the two was that the former was
aspects. However, given that the DSM criteria indicate that there is characterized by abhorrence and disgust while the latter was not.
aversion and avoidance, this implies that the definition of aversion To explore the potential similarities between SAD, HSDD, and
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Arch Sex Behav (2010) 39:271–277 273
worry (the latter was assessed because it is associated with one of the few empirical studies of SAD, 382 college under-
many DSM-IV-TR disorders including anxiety disorders), 138 graduates completed a survey assessing the DSM-III-R diag-
college students completed questionnaires such as the Sexual nostic criteria for SAD (Katz et al., 1989). The 30-item Sexual
Aversion Scale (Katz, Gipson, Kearl, & Kriskovich, 1989), the Aversion Scale (SAS) assessed fears about AIDS, social evalu-
Hurlbert Index of Sexual Desire (Apt & Hurlbert, 1992), and the ation, pregnancy, and sexual trauma. Katz et al. found high
Penn State Worry Questionnaire (Meyer, Miller, Metzger, & internal, test-retest, and item-total reliability of the scale. Katz
Borkovec, 1990). Worry was only weakly associated with both et al. estimated the prevalence of sexual aversion severe en-
sexual aversion and sexual desire scores, leading Janata and ough to warrant treatment seeking to be approximately 10%,
Kingsberg to conclude that worry was not a central feature of the although 29% reported avoidance of nearly all genital contact.
sexual desire disorders. Among those with sexual aversion, there were significant fears
In the DSM-IV-TR, SAD is diagnosed as lifelong or ac- about AIDS, and Katz et al. predicted that such a question-
quired. Crenshaw (1985) noted that occasionally sexual aver- naire would be important if AIDS were to spread to the het-
sion is specific to a certain relationship and that outside of that erosexual population. In a subsequent validation study of the
relationship the person is able to function normally sexually. SAS (Katz, Gipson, & Turner, 1992), scores on this measure
This would be deemed a situational SAD. Janata and Kingsberg were significantly correlated with scores on the Fear Survey
(2005) prefer the categories of primary and secondary to refer to Schedule (Wolpe & Lang, 2007), and individuals with a his-
the acquisition of fear and anxiety before or after, respectively, tory of sexual abuse had higher scores of aversion. Since the
the development of a healthy sexual relationship. A lifelong articles by Katz et al. 20 years ago, I could not locate any
SAD is senseless for the individual who, perhaps, had their additional published studies using the SAS.
sexual debut in their teens, 20s, or even later. Secondly, because Despite the large number of recent population-based epi-
of the leading theory of SAD as being a conditioned and, there- demiological studies on sexual symptoms and distress, none
fore, acquired response, this also implies that it could never have have asked about the prevalence and associated features of
been lifelong for conditioning would have had to take place at sexual aversion. One exception is the large epidemiological
some point in time. Zurich Cohort Study, of which a subset of the questions fo-
Interestingly, there was no change to the essential criterion cused on sexual symptoms in 363 participants. A total of 12
for SAD (extreme aversion to and avoidance of sexual contact) (3.3%) individuals reported feeling ‘‘constantly or once in a
from DSM-III-R to DSM-IV. It is also interesting to note that in while extreme aversion to genital sexual contact’’ which
the DSM-IV Sourcebook (Schiavi, 1996), there was reference to caused ‘‘distinct suffering or relationship conflicts’’ (J. Angst,
only two published empirical papers on SAD and both were personal communication, February 23, 2009). Because of the
published prior to DSM-III-R (American Psychiatric Associ- small sample size, analyses of the associated correlates of
ation, 1987). One study compared 20 sexually aversive indi- sexual aversion were not possible.
viduals with 35 controls. The DSM-IV Sourcebook noted that Knowledge about gender differences in sexual aversion is
no reliability information were provided, but that those with virtually non-existent. However, Kingsberg and Janata (2003)
SAD scored significantly higher on the State-Trait Anxiety noted that SAD primarily affects women and that men with
Inventory (Spielberger, Gorusch, & Lushene, 1970). The only SAD are more likely to avoid relationships and, therefore,
conclusion drawn by the Sexual Dysfunctions Work Group was distress due to sexual contact is less frequent than it is for
that there was no evidence to support ‘‘narrowing the diagnosis women. In the college student sample studied by Katz et al.
of sexual aversion disorder to include individuals with aver- (1989), scores on the SAS were significantly higher for women
sions limited to one or a few components of the sexual inter- than they were for men. Women also worried significantly
action’’ (Schiavi, 1996, p. 1100). However, there was also no more about being evaluated sexually by partners, were more
mention of justification for why SAD should continue to avoidant, and were more fearful of intercourse than men.
remain a diagnosable sexual dysfunction.
Prevalence Causal Mechanisms
The precise prevalence of SAD is unknown and difficult to Janata and Kingsberg (2005) asserted that SAD is likely best
establish given that individuals avoid sexual encounters and conceptualized as a conditioned aversion according to Mow-
therefore seldom present to sex therapy clinics. Based on rer’s (1947) two-factor theory. It is possible that sexual stimuli
clinical experience, Crenshaw (1985) believed that sexual were paired with painful or traumatic sexual stimuli, produc-
aversion syndrome was the most common sexual dysfunction; ing the aversive conditioned response. There is clinical (Janata
however, Crenshaw noted that most clinicians ‘‘miss’’ the & Kingsberg, 2005) and limited empirical (Noll, Trickett, &
diagnosis because they are inexperienced in identifying it. In Putnam, 2003) support for a role for child sexual abuse in the
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etiology of SAD. There are no empirical data supporting the I’m a 24 year old female, and I believe I suffer from sexual
speculation that SAD is due to a partner forcing sex upon an aversion disorder. I find the thought of all genital contact
individual, despite what is claimed in some pop culture sources quite repulsive, and on occasions in the past when guys
(www.marriagebuilders.com). Avoidance behavior then rein- have tried to touch me below the waist I have become very
forces the conditioned avoidance. Because systematic desen- panicky and upset. It’s not that I have no sexual desire, I
sitization has been found effective in two published case stud- do, and I masturbate to orgasm around once a week.
ies of women with SAD (Finch, 2001; Kingsberg & Janata,
In a sample of 376 patients who avoided sex, Kaplan (1987)
2003), SAD was speculated to be similar to other anxiety
found that 21% also met criteria for Inhibited Sexual Desire
disorders which respond quite well to systematic desensitiza-
Disorder (now classified as HSDD). In an empirical test of the
tion (Choy, Fyer, & Lipsitz, 2007). For women, it has been
association between SAD and HSDD, although sexual desire
noted that, in general, SAD is less responsive to behavioral
and sexual aversion scores were significantly correlated (r =
treatment than is HSDD (Schover & LoPiccolo, 1982); how-
.33, p \ .001), sexual aversion scores accounted for only 11%
ever, there are no published studies comparing behavior ther-
of the variance in sexual desire scores (Katz & Jardine, 1999).
apy in HSDD versus SAD. There have been no published
Research on the distinction between desire and aversion is ex-
longitudinal studies exploring the etiology of SAD so state-
tremely limited to outdated studies with poor methodological
ments about proposed mechanisms are based on assertion
design. However, among those seeking treatment for sexual
only. Moreover, there are no published efficacy studies or case
concerns, anxiety was significantly higher among those with
reports on treatment of SAD in men.
sexual aversion compared to those with low sexual desire (Murphy
Kaplan (1987) also believed that Mowrer’s (1947) two-fac-
& Sullivan, 1981). There was no information in the DSM-IV
tor theory explained the etiology of sexual aversion but added
Sourcebook (Schiavi, 1996) justifying SAD as a Sexual Desire
that reinforcement processes were responsible for its mainte-
Disorder.
nance. Specifically, Kaplan argued that the sexual aversion was
maintained because of a vicious cycle of avoidance and rein-
forcement of the avoidance behavior. Because avoidance allows Overlap Between Sexual Aversion Disorder
the individual to be free of the significant sexual anxiety and and Vaginismus
distress, avoidance becomes self-perpetuating and therefore
reinforcing. As reviewed by Binik (2009), there is some overlap between
Kaplan (1987) noted that psychoanalytic theories also at- SAD and vaginismus, the latter of which is defined in DSM-IV
tempt to explain the etiology of SAD in that the phobic anxiety by a recurrent or persistent involuntary vaginal muscle spasm.
is activated among those individuals with unresolved oedipal The International Consultation Committee sponsored by the
conflicts. For those 4–5 year old boys who do not mature from American Urological Association Foundation refined the defi-
the stage of having sexual feelings for their mothers and being nition of vaginismus in recognition of the finding that vaginal
fearful of castration by their fathers, neurotic anxiety (and sex- muscle spasm was not universally present among women with
ual aversion) may develop. Treatment is therefore aimed at vaginismus whereas fear of penetration was. This group de-
resolving the oedipal complex. Unfortunately, this particular scribed vaginismus as ‘‘The persistent or recurrent difficulties of
theory has never been tested directly nor have there been the woman to allow vaginal entry of a penis, a finger, and/or any
empirical tests of the efficacy of psychoanalysis for SAD. object, despite the woman’s expressed wish to do so. There is
often (phobic) avoidance and anticipation/fear of pain’’ (Basson
et al., 2003). Basson et al. highlighted the phobic qualities of
Is Sexual Aversion Disorder a Sexual Desire Disorder? vaginismus and concluded that it was fear of penetration that
characterized vaginismus more than vaginal spasm. Because
Although SAD is listed as one of the two Sexual Desire Disorders, women with vaginismus are fearful of (painful) vaginal pene-
there appear to be few similarities between HSDD and SAD—the tration, this often results in avoidance behavior and even in
former being characterized by the absence of desire and the latter aversion in severe cases. It is possible, therefore, that some cases
as the presence of fear and avoidance. Although Schover and of aversion are due to vaginismus, although both disorders can be
LoPiccolo (1982) conceptualized SAD and HSDD as being at diagnosed simultaneously. Although there are no empirical data
opposite ends of the same spectrum, Kaplan (1987) disagreed that have sought to differentiate these two disorders, vaginismus
with this conceptualization, noting that individuals with SAD can is classified as a sexual pain disorder because of the overlap with
continue to experience normal sexual desire, fantasize, and often dyspareunia. If the aversion is exclusively due to fear of pain, then
masturbate to orgasm. Indeed, internet advice columns (e.g., the diagnosis indeed would be one of vaginismus and not SAD.
psychcentral.com/ask-the-therapist) present queries from indi- Thus, there appears to be enough of a difference in the diagnostic
viduals with SAD symptoms despite apparent normal levels of descriptions of the two disorders to justify their assignment to
sexual desire: different classes of sexual dysfunction.
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Arch Sex Behav (2010) 39:271–277 275
Overlap Between Sexual Aversion Disorder follows Mowrer’s (1947) two-factor theory of pathogenesis
and Specific Phobia and (2) it responds optimally to behavior therapy in the form
of systematic desensitization.
The DSM-IV-TR (American Psychiatric Association, 2000)
criteria for Specific Phobia are listed in Table 2. If one were
to consider these criteria in the context of the feared sexual Recommendations
stimulus, it is readily apparent that the individual with SAD
could meet criteria for a Specific Phobia. Although the text on It is perhaps no coincidence that Sexual Aversion Disorder
SAD indicates that ‘‘…sexual aversion may technically meet was added to the DSM-III-R (American Psychiatric Asso-
the criteria for Specific Phobia, this additional diagnosis is ciation, 1987) under the influence of Kaplan in the same year
not given’’ (American Psychiatric Association, 1994, p. 499), that Sexual Aversion, Sexual Phobias, and Panic Disorder
paradoxically the text on Specific Phobia makes no mention (Kaplan, 1987) was published. Kaplan was a major proponent
of SAD. It might be inferred from these criteria that the for including SAD into the DSM based on clinical observa-
Anxiety Disorders Work Group had not considered the fact tions. However, its inclusion into the diagnostic taxonomy
that SAD could technically overlap with the criteria for has not translated into increased research on the topic (as it
Specific Phobia and therefore did not list it as a Differential perhaps was originally hoped). Instead, there are only a few
Diagnosis. The rationale for why SAD should be classified as case studies published on SAD and, since the publication of
a Sexual Dysfunction and not an Anxiety Disorder is simi- DSM-IV-TR in 2000, there have been no published epide-
larly not clarified. The limited empirical data available sug- miological studies on the topic.
gest that SAD is similar to Specific Phobias in that (1) it likely There are three possible alternatives for dealing with SAD
in DSM-V. The APA draft guidelines for making changes to
Table 2 DSM-IV-TR diagnostic criteria for Specific Phobia (300.29) DSM-V (DSM-V Task Force Document, 2009) provides a list
A. Marked and persistent fear that is excessive or unreasonable, cued by
of five principles to consider when proposing a change to the
the presence or anticipation of a specific object or situation (e.g., DSM. These include: (1) to distinguish between psychiatric
flying, heights, animals, receiving an injection, seeing blood) syndromes for purposes of guiding the most effective treat-
B. Exposure to the phobic stimulus almost invariably provokes an ment and management; (2) to reduce confusion of syndromes
immediate anxiety response, which may take the form of a with each other; (3) to take into account co-morbid symptoms
situationally bound or situationally predisposed Panic Attack.
which affect the outcome of treatment in the most effective
Note: In children, the anxiety may be expressed by crying,
tantrums, freezing, or clinging manner; (4) to facilitate ease of use and promote clinical utility;
C. The person recognizes that the fear is excessive or unreasonable. and (5) to demonstrate validity on as many levels as possible.
Note: In children, this feature may be absent Among the principles that are most relevant to SAD is one that
D. The phobic situation(s) is avoided or else is endured with intense states that the goal is to distinguish among psychiatric syn-
anxiety or distress dromes for purposes of treatment. Changes should also reduce
E. The avoidance, anxious-anticipation, or distress in the feared confusion among syndromes. Both of these points are relevant
situation(s) interferes significantly with the person’s normal routine, to the diagnostic category of SAD given its apparent overlap
occupational (or academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia with phobias and possibly with vaginismus. Thus:
F. In individuals under age 18 years, the duration is less than 6 months Option 1 is to remove SAD from the DSM-V and expand the
G. The anxiety, Panic Attacks, or phobic avoidance associated with the definition of vaginismus to encompass women with sexual
specific object or situation are not better accounted for by another aversion. As noted earlier in this review, some women with
mental disorder, such as Obsessive–Compulsive Disorder (e.g., fear vaginismus experience aversion to sexual activity. Crenshaw
of dirt in someone with an obsession about contamination), (1988) noted that there is a high correlation between primary
Posttraumatic Stress Disorder (e.g., avoidance of stimuli associated
with a severe stressor), Separation Anxiety Disorder (e.g., avoidance sexual aversion and vaginismus in women, but this claim has
of school), Social Phobia (e.g., avoidance of social situations because never been empirically verified. The potential benefit of sub-
of fear of embarrassment), Panic Disorder With Agoraphobia, or suming sexual aversion under the category of vaginismus is
Agoraphobia Without History of Panic Disorder that women with vaginismus would not be further patholo-
Specify type gized by having an additional disorder if they were aversive of
Animal type sex. However, in women with SAD, the aversive stimulus is
Natural environment type (e.g., heights, storms, water) typically genital sexual contact with a partner, not necessarily
Blood–Injection–Injury type fear/anticipation of pain, as in the case of vaginismus. More-
Situational type (e.g., airplanes, elevators, enclosed spaces) over, many (if not most) women with vaginismus also expe-
Other type (e.g., phobic avoidance of situations that may lead to rience comorbid sexual pain, and this is not a clinical feature of
choking, vomiting, or contracting an illness; in children, women with SAD. One might speculate that the aversion to sex
avoidance of loud sounds or costumed characters)
among women with vaginismus is, therefore, adaptive since
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276 Arch Sex Behav (2010) 39:271–277
they are avoiding painful sexual activity. This appears not to be services data, course, and treatment outcome data were non-
the case with SAD. Thus, although some women with vagi- existent. Moreover, the requirement that the disorder in
nismus do experience aversive or phobic-like reactions to question is sufficiently distinct from other disorders to warrant
vaginal penetration, this is not the same group of women designation as a separate disorder was not met and it could
originally conceptualized by Kaplan (1987) as being sexually have been captured as a subtype of another disorder (Specific
aversive. I am not in favor of subsuming sexual aversion under Phobia). It is possible that the historical influence of Kaplan
the category of vaginismus. overshadowed the lack of empirical data justifying SAD as a
Option 2 is to remove SAD from the DSM-V and make the new diagnostic entity. With DSM-V and the emphasis placed
recommendation that cases of genital contact phobia be cap- on any changes being based on empirical science, SAD clearly
tured under the diagnosis of Specific Phobia. This would in- would not have made its way into the DSM.
volve adding to the text description of Specific Phobia that
aversion to sexual contact is one manifestation of phobia in the Acknowledgments The author is a member of the DSM-V Work-
group on Sexual and Gender Identity Disorders. I wish to acknowledge
‘‘Other Type’’ category. It would not be necessary to change the valuable input I received from members of my Workgroup (Yitzchak
the diagnostic criteria for Specific Phobia itself to account for Binik, Cynthia Graham, R. Taylor Segraves) and Kenneth J. Zucker.
sexual aversion given that, as outlined earlier, if one were to Feedback from DSM-V Advisors Richard Balon and Sheryl Kingsberg
substitute ‘‘sexual stimulus’’ for ‘‘specific object’’ or ‘‘stimu- is greatly appreciated. Reprinted with permission from the Diagnos-
tic and Statistical Manual of Mental Disorders V Workgroup Reports
lus’’ in the criteria, this description captures the entity of SAD (Copyright 2009), American Psychiatric Association.
already. It is unclear why the DSM-IV-TR text description of
SAD indicates that a diagnosis of Specific Phobia should not be
given if one has SAD, particularly as a parallel statement is not References
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pathophysiological research, and the apparent overlap with sitization [Letter to the Editor]. Canadian Journal of Psychiatry, 46,
563–564.
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considered for inclusion into DSM-III-R, it would not have Katz, R. C., Gipson, M. T., Kearl, A., & Kriskovich, M. (1989). Assessing
passed the test. Reliability and validity data on the diagnostic sexual aversion in college students: The Sexual Aversion Scale.
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drome was unknown, there were insufficient data published on Sexual Aversion Scale. Journal of Sex and Marital Therapy, 18,
a range of topics related to SAD, and epidemiological and 141–146.
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DOI 10.1007/s10508-009-9560-0
ORIGINAL PAPER
The DSM Diagnostic Criteria for Vaginismus

Yitzchak M. Binik

Abstract Vaginal spasm has been considered the defining mus for approximately 150 years. This diagnostic criterion is
diagnostic characteristic of vaginismus for approximately 150 currently formulated in the fourth edition of the Diagnostic
years. This remarkable consensus, based primarily on expert and Statistical Manual of Mental Disorders (DSM) (American
clinical opinion, is preserved in the DSM-IV-TR. The available Psychiatric Association, 2000) as follows:
empiricalresearch,however,doesnotsupportthisdefinitionnor
A. Recurrent or persistent involuntary spasm of the mus-
does it support the validity of the DSM-IV-TR distinction be-
culature of the outer third of the vagina that interferes
tween vaginismus and dyspareunia. The small body of research
with sexual intercourse.
concerning other possible ways or methods of diagnosing vag-
inismus is critically reviewed. Based on this review, it is pro- The other DSM-IV diagnostic criteria for vaginismus are
posed that the diagnoses of vaginismus and dyspareunia be identical to those for all of the other sexual dysfunctions:
collapsed into a single diagnostic entity called ‘‘genito-pelvic
B. The disturbance causes marked distress or interpersonal
pain/penetration disorder.’’ This diagnostic category is defined
difficulty.
according to the following five dimensions: percentage success
C. The disturbance is not better accounted for by another
of vaginal penetration; pain with vaginal penetration; fear of
Axis I disorder (e.g., Somatization Disorder) and is not
vaginal penetration or of genito-pelvic pain during vaginal pen-
due exclusively to the direct physiological effects of a
etration; pelvicfloormuscledysfunction;medicalco-morbidity.
general medical condition.
Keywords DSM-V Vaginismus Dyspareunia Specify Type: Lifelong/Acquired
Sexual pain Muscle spasm Specify Type: Generalized/Situational
Specify Due to: Psychological Factors/Combined
Factors.
Introduction
Involuntary vaginal muscle spasm (Criterion A) may con-
stitute one of the most long lasting psychiatric diagnoses ever.
The most remarkable feature of the diagnostic literature con-
While longevity suggestsutility and validity, itcan alsosuggest
cerning vaginismus is its lack of controversy. Vaginal muscle
neglect. Unfortunately, it appears that the latter is the case. An
spasm has been the defining diagnostic criterion for vaginis-
examination of the history and development of the diagnosis of
vaginismus will set the stage for understanding the very recent
empirical work that has challenged this very durable muscle
Y. M. Binik (&) spasm conceptualization.
Department of Psychology, McGill University, 1205 Dr. Penfield
Ave., Montreal, QC H3A 1B1, Canada
e-mail: [email protected] History of the Muscle Spasm Diagnosis of Vaginismus
Y. M. Binik
Sex and Couple Therapy Service, McGill University Health The central role of vaginal muscle spasm as the defining feature
Center, Montreal, QC, Canada of vaginismus has a very long history. A 1547 work, entitled
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Arch Sex Behav (2010) 39:278–291 279
‘‘The Diseases of Women’’ (Trotula of Salerno, 1940), may The literature has remarked on an unusual physical re-
have been the first to allude to this by describing ‘‘a tightening of sponse pattern of a woman afflicted with vaginismus. She
the vulva so that even a woman who has been seduced may reacts in an established pattern to psychological stress dur-
appear a virgin’’ (p. 37). Huguier (1834) was the first to describe ing a routine pelvic examination that includes observation
the syndrome, which Sims (1861) later named vaginismus and of the external genitalia and manual vaginal exploration.
described as an ‘‘involuntary spasmodic closure of the mouth of The patient usually attempts to escape the examiner’s ap-
the vagina, attended with such excessive supersensitiveness as proach by withdrawing toward the head of the table, even
to form a complete barrier to coition’’ (p. 362). In fact, Sims’ raising her legs from the stirrups, and/or constricting her
definition was reinforced by modern authorities no less than thighs in the midline to avoid the implied threat of the im-
Masters and Johnson (1970), who vividly described a ‘‘spastic’’ pending vaginal examination. Frequently this reaction
and an ‘‘involuntary reflex’’ of the pelvic musculature, ‘‘… affect- pattern can be elicited by the woman’s mere anticipation of
ing a woman’s freedom of sexual response by severely, if not the examiner’s physical approach to pelvic examination
totally, impeding coital function’’ (p. 250). This muscle spasm rather than the actual act of manual pelvic investigation.
definition first appeared in the third edition of the DSM (Amer- (pp. 250–251)
ican Psychiatric Association, 1980) and has remained essentially
The difficulty in performing such a diagnostic examination
unchanged through DSM-IV-TR.
has resulted in the understandable reluctance of many gynecol-
Sims (1861) also suggested that vaginismus constituted a
ogists to carry them out. Some have suggested that such exam-
‘‘distinct affection’’ (p. 361), laying the groundwork for the
inations should be delayed for fear of traumatizing the woman
DSM’s and all other classification systems’ categorical con-
and making therapy more difficult (Bollapragada & Melrose,
ceptualization. Although there have been suggestions (e.g.,
2008; Crowley, Goldmeier, & Hiller, 2009; Crowley, Richard-
Lamont, 1978) that vaginismus and dyspareunia (‘‘Recurrent
son, & Goldmeier, 2006; Drenth, 1988; Pedersen & Mohl, 1992;
or persistent genital pain associated with sexual intercourse in
Reamy, 1982). The net result appears to have been that an un-
either a male or female,’’ p. 556 in the DSM-IV-TR) overlap
known number of women were diagnosed with vaginismus based
and that vaginal penetration difficulties can be ‘‘partial’’ or
on their self-reported difficulty in achieving vaginal-penile pen-
‘‘total,’’ vaginismus has traditionally been conceptualized as a
etration and their avoidance of pelvic examinations.
distinct syndrome and different from dyspareunia. For reasons
that are not justified, the DSM-IV-TR (American Psychiatric
Association, 2000) does not allow for joint diagnoses of vagi- Self-Report
nismus and dyspareunia (see p. 557).
There are no published instruments or algorithms that trans-
Method of Diagnosis late self-report into the DSM-IV-TR diagnosis of vaginismus.
Neither the Structured Clinical Interview for DSM Disorders
Masters and Johnson (1970) insisted that a reliable diagnosis (First, Spitzer, Gibbon, & Williams, 1997) nor the Diagnostic
of vaginismus could not be made by mental health profession- Interview Schedule (Robins, Helzer, Croughan, & Ratcliff,
als unless they were able to carry out a pelvic examination. The 1981) has included a section on sexual dysfunction. Although
DSM-IV-TR does not deal with this issue directly though it does there are a large number of psychometric instruments that
acknowledge that many diagnoses of vaginismus are made dur- have been developed to assess sexual dysfunction, only one
ing gynecological examinations (American Psychiatric Associ- commonly used one, the Golombok Rust Inventory of Sexual
ation, 2000, p. 557). It also suggests that some women may suffer Satisfaction (GRISS) (Rust & Golombok, 1998), specifically
from situational vaginismus where they may be able to tolerate assesses vaginismus. The GRISS includes a vaginismus scale
gynecological examinations but not penile penetration. There is that is made up of the following four questions rated on a five-
no explanation given for how this pattern of symptoms is to be point response scale ranging from ‘‘never’’ to ‘‘always’’:
diagnosed. It is my impression that it is very rare for current day
psychiatrists to carry out pelvic examinations. If this is correct, 1. ‘‘Do you find that your vagina is so tight that your part-
thenthediagnosisofvaginismusistypicallymadetodayeitherby ner’s penis cannot enter it?’’
a gynecologist during a pelvic examination or by a mental health 2. ‘‘Is it possible to insert your finger into your vagina with-
professional based on the client’s self-report. out discomfort?’’
3. ‘‘Is it possible for your partner’s penis to enter your va-
Pelvic Examination gina without discomfort?’’
4. ‘‘Do you find that your vagina is rather tight so that your
Masters and Johnson (1970) provided a vivid clinical descrip- partner’s penis can’t penetrate very far?’’
tion of a typical vaginismic woman’s behavior during a pelvic While these questions are definitely relevant, they overlap with
examination: those that would be used by a mental health clinician trying to
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280 Arch Sex Behav (2010) 39:278–291
diagnose vaginismus. They are not sufficient to make a DSM the DSM-IV-TR ‘‘diagnostic features’’ section of sexual aver-
IV-TR diagnosis since the diagnosis requires confirmation of sion disorder, it notes that there are women who manifest fear,
spasm. They are also not sufficient to differentiate vaginismus anxiety, and/or disgust to vaginal penetration specifically (see
fromdyspareunia. Forexample,a woman whoanswers‘‘usually’’ p. 541). In principle, the DSM IV-TR allows for the joint diag-
to Questions 1 and 4 and ‘‘hardly ever’’ to Questions 2 and 3 nosis of vaginismus with sexual aversion disorder, though it is
might be reasonably diagnosed with either vaginismus or dys- my impression that this is rarely done because there is only a
pareunia. very small literature on this diagnosis, which suggests that it
may not be made frequently.
Non-Spasm Based Features of Vaginismus
Summary
Masters and Johnson’s (1970) description of a pelvic exami-
nation suggests a number of other possible clinical character- The vaginal muscle spasm diagnostic formulations for vaginis-
istics of vaginismus, including pain and fear of vaginal penetra mus were almost entirely based on expert clinician opinion. By
tion. In their view, these characteristics were secondary to vag- the date of publication of the DSM-IV-TR in 2000, no one had
inal spasm. However, other clinical investigators and some ever empirically demonstrated that vaginismus was characterized
classification systems have stressed these non-spasm related by pelvic muscle spasm, was differentiable from dyspareunia or
features. For example, several classification systems have emp- was reliably diagnosable. Non-muscle spasm diagnostic charac-
hasized the role of experienced or anticipated pain in vaginis- teristics, such as pain or fear, were often acknowledged indirectly
mus. These systems include those proposed by the World Health in the DSM or other classification systems but not deemed essen-
Organization (ICD-10) (1992), International Association for the tial.
Study of Pain (Merskey & Bogduk, 1994), American College of Whytherewassolittlecontroversyandempiricalresearchisnot
Obstetrics and Gynecology (1995), and Lamont (1978). Unfor- clear. Researchers may have been deterred by a variety of factors,
tunately, the descriptive characteristics of the pain were never including the presumed low prevalence of vaginismus, the diffi-
specified nor was the relationship of the pain to muscle spasm. cultyassociatedwithcarryingoutgynecologicalexaminations,and
Moreover, pain never supplants muscle spasm as the crucial the worry that the examinations themselves might be iatrogenic.
diagnostic factor. The DSM-IV-TR does acknowledge the role There was probably also the tacit but invalid assumption that the
of pain in vaginismus in two ways: (1) vaginismus is subclas- diagnosis was reliable because treatments modeled after the Mas-
sified with dyspareunia as a sexual pain disorder; (2) pain is also ters and Johnson (1970) approach were thought to be highly effi-
mentioned under ‘‘associated features and disorders’’ as the cacious. Perhaps most important was the fact that vaginismus is the
possible result of intense and long-lasting muscle contraction/ only DSM-IV-TR diagnosis that relies primarily on non-psychi-
spasm. Nonetheless, pain is not assigned any crucial diagnostic atric clinicians. Mental health professionals could not actually do a
significance. diagnosticreliabilitystudywithoutaparticipatinggynecologistand
Fear of pain or fear of penetration also features prominently few gynecologists appeared to be interested.
in many clinical descriptions (e.g., Blazer, 1964; Byford, 1902; The diagnostic requirement of a physical examination sug-
O’Sullivan & Barnes, 1978; Ohkawa, 2001; Walthard, 1909; gests another unique aspect of the definition of vaginismus. It is
Wijma & Wijma, 1997). For example, Kaplan (1974) described the only DSM-IV-TR sexual dysfunction (and possibly Axis I)
this in the following way: diagnosis that relies on a physical symptom that is not based on
self-reported or observed behavior and/or internal states. Al-
In addition to the primary spasm of the vaginal inlet, pa-
though the DSM-IV-TR sometimes mentions ‘‘associated phys-
tients with vaginismus are also usually phobic of coitus
ical examination’’ or ‘‘associated laboratory’’ findings for other
and vaginal penetration. This phobic avoidance makes
disorders, these are not typically crucial for making a diagnosis.
attempts at coitus frustrating and painful. It is often a sec-
It is strange that there is no suggestion that women be directly
ondary reaction to the primary vaginismus, but some-
asked if they experience spasm during attempted penetration.
times the penetration phobia antedates the vaginismus.
This question would not be an uncommon one for a physician to
(p. 412)
ask a patient concerning spasms experienced elsewhere in the
Although Kaplan and others emphasized the fear/phobic aspect body.
of vaginismus, they did not exclude spasm as the primary diag- The DSM-IV-TR not only specifies ‘‘vaginal muscle spasm’’
nostic feature. There do not appear to be any formal diagnos- as the defining symptom, it treats this symptom as the ‘‘cause’’
tic systems that characterize vaginismus as a phobic state. The for the interference with intercourse (‘‘Recurrent or persistent
DSM-IV-TR may have relegated this aspect of vaginismus to involuntary spasm of the musculature of the outer third of the
sexual aversion disorder, which is characterized by ‘‘extreme vagina that interferes with sexual intercourse,’’ p. 558). This
aversion to, and avoidance of…genital sexual contact with a mechanistic type language is not in line with the general strategy
partner’’ (American Psychiatric Association, 2000, p. 542). In of the DSM-IV-TR to classify by symptoms rather than by
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Arch Sex Behav (2010) 39:278–291 281
presumed cause or mechanism. This exception is an unfortunate diagnosed with vaginismus and normal controls. Reissing, Bi-
one, in my view, since there appear to be little data (see below) to nik, Khalifé, Cohen, and Amsel (2004), however, found sig-
support vaginal muscle spasm as the defining symptom or as nificant sEMG muscle tone but not strength differences between
the exclusive cause for interference with intercourse. Recently, women diagnosed with vaginismus and matched normal con-
these and other classification issues related to vaginismus have trols but no significant differences at all between the vaginismus
been examined empirically. This research is reviewed under three and dyspareunia/VVS (aka provoked vestibulodynia) groups.
overlapping categories examining the following questions: (1) One needle EMG study (Shafik & El-Sibai, 2002) found that
Does muscle spasm characterize vaginismus? (2) Is vaginismus a basal but not reactive (i.e., to possible penetration) EMG activity
‘‘distinct affection’’? (3) Can non-muscle based symptoms dif- in the levator ani, puborectalis, and bulbocavernosus muscles
ferentially diagnose vaginismus from dyspareunia? was significantly higher in women diagnosed with vaginismus
than in normal controls. A second needle electrode study mea-
suring activity in the levator ani and external anal sphincter
Empirical Studies of the Diagnosis of Vaginismus muscles (Frasson et al., 2009) also found significant basal
hyperexcitability in addition to significant reactive (i.e., during
Does Muscle Spasm Characterize Vaginismus? ‘‘straining’’) EMG differences between a mixed group of vag-
inismus/VVS patients and controls. Two additional sEMG
Because of the 150 year consensus concerning the nature of vag- studies (van der Velde & Everaerd, 2001; van der Velde, Laan,
inismus, most clinical reports and etiological studies take for & Everaerd, 2001) have been carried out in which women
granted that women diagnosed with vaginismus exhibit vaginal watched film clips of erotic, neutral or sexually threatening
muscle spasm upon attempted vaginal penetration. The actual ex- content. There were no significant EMG differences between
istence of this vaginal muscle spasm, however, had never been women suffering from vaginismus and normal controls.
empirically examined prior to the publication of DSM-IV-TR. It Overall, the evidence from EMG studies does not strongly
had also never been empirically determined that two indepen- support a vaginal muscle spasm mechanism specific to vagi-
dent gynecologists could reliably diagnose vaginal spasm. This nismus. None of the existing studies report EMG evidence for
situation has resulted in a problematic research situation where spasm. In addition, there is little consistent evidence that muscle
any woman who could not experience vaginal penetration and did tone or strength differences can differentiate vaginismus from
not experience spasm could not receive a DSM-IV-TR diagnosis dyspareunia. Moreover, there are a variety of problems using
of vaginismus and, therefore, could not be included in any study EMG methodology in this context. Surface EMG can only give
based on DSM-IV-TR criteria. Since it is very difficult to publish a global measure of muscle strength or tone and cannot deter-
research in a reputable journal that does not use DSM IV-TR mine which muscles are affected. Most important, perhaps, is
criteria, this circularity may have helped to impede the necessary that a large percentage of women diagnosed with vaginismus
diagnostic research. are not able or willing to insert an sEMG probe, making this type
of measurement impossible. While the use of needle electrodes
Electromyography (EMG) Studies avoids this problem, it is not clear into which muscles to insert
the needles and the process of insertion is in itself very painful.
One possible way of examining the muscle spasm hypothesis of
vaginismus is through the use of EMG measurement. In surface Muscle Spasm Reliability Studies
electromyography (sEMG), a tampon-like probe is inserted into
the vagina (and/or anus) and a global measure of pelvic muscle A second empirical way of examining the muscle spasm
tension is recorded at baseline and in response to specific instruc- hypothesis is to investigate whether gynecologists can reliably
tions to contract or relax relevant muscles. An alternative method, diagnose muscle spasm. This has been taken for granted in the
needle EMG, requires the insertion of needle electrodes into a vaginismus literature. In the context of a larger study, Reissing
specific muscle. Women suffering from vaginismus would be et al. (2004) asked two gynecologists and two pelvic floor
expected to demonstrate spasm (or muscle tone and strength dif- physiotherapists to examine women suffering from either vag-
ferences from controls) as measured by EMG either at baseline or inismus or dyspareunia/VVS and normal controls and to assess
in response to contraction/relaxation instructions or to an external whether these women also suffered from muscle spasm, height-
stimulus. ened muscle tone or reduced muscle strength. Women in the
There have been seven EMG studies examining women vaginismus group were not required, a priori, to demonstrate
suffering from vaginismus. Engman, Lindehammar, and Wijma reliable vaginal muscle spasm as required by the DSM-IV-TR
(2004) found no significant differences in sEMG measures be- since this would preclude testing the reliability hypothesis. In
tween women diagnosed with vaginismus and women suffering order to circumvent this circularity, Reissing et al. developed a
from dyspareunia or matched controls. Similarly, van der Velde detailed set of behavioral inclusion criteria for the vaginismus
(1999) found no significant sEMG differences between women group that were similar to what mental health clinicians might
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282 Arch Sex Behav (2010) 39:278–291
typically use in the absence of a gynecological examination. experimenter if they experienced vaginal spasm during pene-
These included the following: tration; only 24% said yes.
Based on this one study, there is no evidence that gynecol-
1. Never having been able to experience vaginal intercourse,
ogists (or pelvic floor physical therapists) can reliably diagnose
despite attempts on at least 10 separate occasions or
vaginal muscle spasm/tone/strength in women suffering from
2. Never having been able to experience vaginal intercourse
vaginismus. This is not totally surprising since there is some in-
despite attempts on at least two separate occasions and oth-
dication in the myography literature that the concept of spasm it-
er interference with vaginal penetration (see below) or
self is not very clearly defined (Johnson, 1989; Simons & Mense,
3. A current inability to experience vaginal intercourse and oth-
1998). This situation may improve since protocols (Reissing,
er interference with vaginal penetration for at least 1 year, al-
Brown, Lord, Binik, & Khalife, 2005) and a new instrument
though vaginal penetration was experienced at least once
(a dynamometric speculum) (Morin et al., in press) for assess-
before this period.
ing muscle tone/strength are now being developed; unfortu-
Other interference with vaginal penetration was defined as an nately, these have not been adequately evaluated in women
average of less than one attempt at vaginal intercourse every two suffering from vaginismus and dyspareunia.
months over the past year despite adequate opportunity or being
involved in a relationship, and also meeting one of the following
two criteria: (1) never having seen a health professional for, or Summary
never having successfully completed, a pelvic exam; (2) never
having used tampons. Despite almost 150 years of consensus, there is no empirical
The results of this study were striking. Based on the gyne- evidence to support vaginal/pelvic muscle spasm as the defining
cological examination, women in the vaginismus group dem- characteristic of vaginismus. While it appears possible that a
onstrated a higher frequency of vaginal spasm than women in subset of women currently diagnosed with vaginismus do suffer
the dyspareunia/VVS and normal control groups. There were no from vaginal/pelvic spasm, it is likely a minority. It is odd that
significant differences in vaginal spasm between the dyspa- researchers never bothered until recently (Reissing et al., 2004)
reunia/VVS and normal control groups. However, less than a to specifically ask women suffering from vaginismus whether
third of women suffering from vaginismus were considered by they suffered from spasm. When this was finally done, less than
the gynecologists to have experienced vaginal spasm during the a quarter said yes. An older study (Ward & Ogden, 1994) which
examination. For gynecologists, the overall diagnostic agree- asked vaginismic women about their attributions for not being
ment for assigning women into the three groups was ‘‘moder- able to have intercourse also suggests that few blamed spasm.
ate’’ (kappa = .60). They had high percentages of diagnostic Overall, there is inconsistent empirical indication about whether
agreement for dyspareunia/VVS and for normal controls but measures of vaginal/pelvic muscle tone or strength can differ-
they disagreed most of the time concerning the diagnosis of entiate women suffering from vaginismus from controls but
vaginismus. there is a great deal of overlap on these measures between
There was a different pattern of diagnostic agreement for vaginismic and dyspareunic women. New instruments under
the pelvic floor physical therapists. Women in the normal con- development (Morin et al., in press) may provide for more
trol group were assessed to have significantly fewer vaginal sensitive and reliable measurement of the muscle tone/strength
spasms than women both in the vaginismus or dyspareunia/ of the pelvic floor; however, these instruments have not yet been
VVS groups. However, no significant differences in the fre- tested in women suffering from vaginismus and dyspareunia.
quency of vaginal spasm were noted between the vaginismus
and dyspareunia/VVS groups. The overall rate of detecting vag-
inal spasms was much higher for the physical therapists than for Is Vaginismus a ‘‘Distinct Affection’’?
the gynecologists. One or both physical therapists reported a
vaginal muscle spasm in 86% of women in the vaginismus Partial vs. Total Vaginismus
group, in 93% of women in the dyspareunia/VVS group, and
in 54% of women in the normal control group. While the over- Starting with Sims’ (1861) assertion that vaginismus is a
all level of diagnostic agreement for the pelvic floor physi- ‘‘distinct affection,’’ vaginismus has generally been consid-
cal therapists was ‘‘substantial’’ (kappa = .64), they tended to ered an ‘‘all or nothing’’ phenomenon and has almost always
agree much more than gynecologists on the diagnosis of vagi- been classified categorically (for a possible exception, see
nismus and less than gynecologists on the diagnosis of dyspa- Lamont, 1978). Recently, a group of Swedish investigators
reunia/VVS. However, both gynecologists and pelvic floor have raised the possibility of a dimensional approach by
physical therapists were good at differentiating women in the suggesting that it is useful to diagnose partial versus total
normal control groups from those in the other two groups. Fi- vaginismus. Total vaginismus was defined by the following
nally, women in the vaginismus group were asked by the criteria (Engman, 2007):
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Arch Sex Behav (2010) 39:278–291 283
1. severe contraction of pelvic floor muscles preventing pen- the basis of muscle spasm/tone/strength measures and by clinical
etration reports that other symptoms such as pain or fear might be imp-
2. the contraction is beyond the control of the women. ortant in differentiating vaginismus from dyspareunia.
One of the following was also required:
1. attempts of penetration are simultaneously accompanied Pain
by burning pain and feared or avoided
2. there is a pronounced fear or avoidance of vaginal pen- The majority of women diagnosed with vaginismus also
etration including all attempts of penetration. experience vulvar pain upon gynecological examination
(e.g., Basson, 1996; de Kruiff, ter Kuile, Weijenborg, & van
Partial vaginismus was defined as follows:
Lankveld, 2000; Engman et al., 2007, 2008; Kaneko, 2001;
… a reflex contraction of the pelvic floor muscles that Reissing et al., 2004). This vulvar pain is typically diagnosed
partly closes the vagina during penetration or attempt to as VVS. There is substantial variation in the reported per-
penetrate….The reflex contraction makes penetration dif- centages of vaginismic women who experience vulvar pain
ficult, but not impossible; is beyond the control of the (from about 40% to almost 100%) but there is little doubt of
woman; and is simultaneously accompanied by burning significant comorbidity. It is likely that this variation may be
pain….The reflex contraction of the pelvic floor muscles related to sampling error, the method of determining VVS/
was ascertained by palpation with one or two fingers vulvar pain or the difficulties in actually examining some
during a pelvic examination, and every reflex contraction women diagnosed with vaginismus. Overall, it is clear that it
of the muscles simultaneously accompanied by the wo- is not currently possible to reliably differentiate vaginismus
man’s report of burning pain was defined as partial vag- from VVS using pain measures. ter Kuile, van Lankveld,
inismus. (p. 2) Vlieland, Willekes, and Weijenborg (2005) concluded that
‘‘pain is an integral part of the experience in the majority of
In two published studies and a doctoral thesis (Engman,
women with lifelong vaginismus’’ (p. 245).
2007; Engman, Wijma, & Wijma, 2007, 2008), women were
Fear/distress or related behaviors have also been empirically
classified with partial vaginismus with or without additional
investigated as potential differentiators between vaginismus and
diagnoses of VVS. In this clinical sample of 224 women, there
dyspareunia. In the Reissing et al. (2004) muscle spasm diag-
was great overlap between the diagnoses of partial vaginismus
nostic reliability study reviewed above, gynecologists rated the
and VVS, i.e., all women diagnosed with VVS also met criteria
behavior of all the patients they examined on a 0–4 scale (0 = no
for partial vaginismus. It was suggested that there were two
problematic reaction; 1 = tension; 2 = close legs/pelvic with-
possible additional symptoms/characteristics of partial vagi-
drawal; 3 = pronounced tension and pelvic withdrawal; 4 =
nismus, including itch (location not specified but presumably
participant terminated the exam). Physical therapists also rated
vaginal) and pain after intercourse.
women during their examinations on a similar list of behaviors
that they termed protective or defensive (e.g., closing knees,
Summary moving away, etc.). Both the gynecologists and physical thera-
pists rated the women in the vaginismus group as exhibiting more
This research does not provide crucial empirical data to confirm defensive, protective, and avoidant behaviors during their exam-
the reliability of the distinction between total and partial vagi- inations than women in the dyspareunia/VVS and normal control
nismus. Moreover, the diagnosis of partial vaginismus in this groups. Reissing et al. described this behavior as similar to that
research greatly overlaps with the diagnosis of VVS. All the of fearful/phobic individuals when confronted with their feared
women who met the VVS cotton swab pain criteria were also stimulus.
diagnosed with partial vaginismus; there were no findings pre- Lahaie, Binik, Amsel, and Khalifé (2008) further investigated
sented to characterize the women with partial vaginismus who the fear hypothesis by recruiting 50 women suffering from vag-
did not meet the criteria for VVS. inismus, and two additional age matched control groups con-
sisting of women suffering from VVS and normal controls.
Subjects were recruited and assigned to experimental group
Can Non-Muscle Based Symptoms Differentially status based on criteria similar to those of Reissing et al. (2004).
Diagnose Vaginismus from Dyspareunia? All subjects underwent a standardized protocol, including a
structured interview, psychometric testing (Fear Survey Sche-
There are a number of studies which try to differentiate vaginis- dule [Wolpe & Lang, 1964]; Fear of Vaginal Penetration Survey,
mus from dyspareunia on a variety of non-muscle spasm based Disgust Sensitivity Index, the State-Trait Anxiety Inventory
measures or methods. These studies were probably motivated by [Spielberger, Gorsuch, & Lushene, 1970], Fear of Pain Ques-
the difficulty in differentiating vaginismus from dyspareunia on tionnaire [McNeil & Rainwater, 1998], Pain Catastrophizing
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284 Arch Sex Behav (2010) 39:278–291
Scale [Sullivan, Bishop, & Pivik, 1995]), and a standardized more than vaginismus. Reissing et al. (2004) carried out a
gynecological examination. During the gynecological exam- structured interview concerning pain and penetration difficul-
ination, heart rate and skin conductance were continuously ties with women suffering from vaginismus, VVS, and with nor-
monitored. In addition, the subjects’ behavior during the gy- mal controls. Reissing et al. asked two Ph.D. level psychologists
necological examination was videotaped and independently to review these transcripts and determine a DSM-IV diagnosis
rated by trained observers blind to experimental group mem- of sexual or other dysfunction. The psychologists agreed on the
bership. diagnosis of vaginismus 21 out of a potential 29 times. Klassen
Although the data are not yet fully analyzed, interim analyses and ter Kuile (2009) have developed a vaginal penetration cog-
of the self-report, psychophysiological, and behavioral data sug- nition questionnaire; initial evaluation of this scale suggests
gest that fear/distress about vaginal penetration may character- promising psychometric characteristics and some ability to dif-
ize many women typically diagnosed with vaginismus. For ex- ferentiate between vaginismus and dyspareunia.
ample, almost two-thirds of the women in the vaginismus group
reported that the main reason they avoided a gynecological
Summary
examination was fear. Fear ratings by the participants and the
gynecologist during the examination significantly differentiated
Without providing any rationale, the DSM-IV-TR prohibits
all groups, with women in the vaginismus group demonstrating
co-existing diagnoses of vaginismus and dyspareunia. Be-
the highest levels. The psychometric evidence also suggests that
cause the majority of women diagnosed with vaginismus expe-
women in the vaginismus group were more fearful in general
rience vulvar pain, this prohibition appears unjustified. The
and more fearful of vaginal penetration than women in the VVS
attempts to differentiate vaginismus and dyspareunia based
and normal control groups. Behavioral ‘‘fear’’ or ‘‘protective’’
on self-report or interview focus on the extent of interference
reactions, such as closing of the legs and pelvic withdrawal, also
with intercourse and the reasons for this interference. These
significantly differentiated all three groups, as did heart rate.
attempts have not been successful because the extent of, and
Perhaps the strongest indicator of fear was that 44.9% of wom-
reasons for, interference are not well specified in the DSM-
en in the vaginismus group discontinued the gynecological ex-
IV-TR. A better specification such as the one proposed by
amination as opposed to 6.4% in the VVS and 2.3% in the
Klassen and ter Kuile (2009) might lead to better results. Fear
normal controls. Nonetheless, there was significant overlap
measures may provide the best way to differentiate vaginis-
between women in the vaginismus and VVS groups on general
mus and dyspareunia but the data to date are preliminary.
anxiety, fear of pain, skin conductance, and pain catastrophizing
even though both of these groups scored significantly higher
than controls.
Conclusions and Recommendations
Self-Reported Behavior The empirical literature concerning the diagnosis of vaginis-

mus is very small and consists of only about 20 relevant pub-
Traditionally, DSM diagnoses have been made on the basis of lications. It is interesting that almost all of these studies are
psychiatric interview. There has never been a strong motivation to the result of the efforts of three separate research groups in
develop such an interview for vaginismus since the diagnosis of Canada, Holland, and Sweden. So far, most of these studies
vaginismus could only be confirmed by gynecological exami- are characterized by relatively small sample sizes, different
nation. There have, however, been three preliminary attempts to recruitment methods, idiosyncratic methodologies, and lack
use interviews or questionnaires to diagnose vaginismus or to of independent replication. Despite these problems, there is
differentiate it from dyspareunia. converging empirical consensus on two issues: (1) Muscle
In an unpublished study, van der Velde (1999) assessed the spasm is not an adequate defining characteristic for vaginis-
diagnostic agreement of two independent raters who reviewed a mus; (2) As currently defined by the DSM-IV-TR, vaginis-
questionnaire concerning ‘‘pelvic floor complaints’’ completed mus and ‘‘penetration type’’ or ‘‘superficial’’ dyspareunia
by 46 women who ‘‘reported that they were suffering from resulting from VVS cannot be reliably differentiated.
vaginismus’’ and 65 controls. There was a 79% rate of diag- Based on this evidence, the current DSM-IV-TR criteria
nostic agreement between raters and substantial agreement for the diagnosis of vaginismus cannot be empirically justi-
(86%) between questionnaire ratings and the results of a gyne- fied. Unfortunately, there are insufficient new data to recon-
cological examination that was also carried out. Unfortunately, struct this category or to propose a replacement. Given this
the questionnaire used in this study was not specified and the unsatisfying situation, there are at least three possible future
definition of ‘‘pelvic floor problems’’ appears to have included classification strategies.
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Arch Sex Behav (2010) 39:278–291 285
Option 1 strategy would essentially constitute what might be called a

vaginal penetration phobia. Whether this should be a sexual dys-
The first strategy is to preserve the category of vaginismus but to function or not is debatable.
redefine it behaviorally. For example, Basson et al. (2004) have
proposed the following definition for vaginismus based on the
Option 3
outcome of discussions of an international sexual medicine con-
sensus conference:
The third strategy is to discard the category of vaginismus and to
The persistent or recurrent difficulties of the woman to suggest a wider multidimensional diagnosis that might be termed
allow vaginal entry of a penis, a finger, and/or any object, ‘‘genito-pelvic pain/penetration disorder.’’ This diagnosis would
despite the woman’s expressed wish to do so. There is include most women currently diagnosed with vaginismus and
often (phobic) avoidance, involuntary pelvic muscle con- dyspareunia. Women complaining of difficulties with vaginal
traction, and anticipation/fear/experience of pain. Struc- penetration would be assessed on five dimensions: (1) percent-
tural or other physical abnormalities must be ruled out/ age success of vaginal penetration; (2) pain with vaginal pene-
addressed. (p. 45) tration; (3) fear of vaginal penetration or of genito-pelvic pain
during vaginal penetration; (4) pelvic floor muscle dysfunction;
This definition preserves the core behavioral characteristic of
(5) medical co-morbidity.
vaginismus, i.e., the inability to experience vaginal penetration
Womencouldbediagnosedwithgenito-pelvicpain/penetration
when desired. It also acknowledges thehigh levelsof comorbidity
by reaching a threshold on any of the first four dimensions above.
among vaginismus, dyspareunia, pelvic floor dysfunction, phobic
The first three dimensions would be assessed by a mental health
states, and medical pathology and would potentially allow for
professional based on a woman’s self report. Pelvic floor muscle
some of these diagnoses to be made by other professionals. The
dysfunctioncouldalsobeassessedonaninterimbasisbyawoman’s
diagnosis of vaginismus, however, could be made by a mental
self report but a more formal assessment by a pelvic floor physical
health clinician alone.
therapist or an appropriate physician would be recommended.
This type of definition is problematic in a variety of ways. The
Degree of medical co-morbidity would require an appropriate uro-
terms ‘‘persistent’’ and ‘‘recurrent’’ would have to be carefully
dermato-gynecological examination (see Appendix for recom-
and operationally defined as would a method for assessing a
mended details of the assessment of all five dimensions).
woman’s ‘‘wish’’ to have penetration. More important, perhaps, is
I recommend this option because it reflects our current
the conceptual question of whether this definition would result in
state of (lack of) knowledge in the following ways:
a ‘‘valid’’ category since the degree of overlap of this diagnosis
with that of dyspareunia, pelvic floor dysfunction, and phobic 1. It makes no assumptions about what causes the inability
avoidance states would be very high. It is also not clear that to experience vaginal penetration.
structural orphysical abnormalitiesshouldberuledout first ifthey 2. It reflects the dimensional nature of the factors involved (e.g.,
co-exist with other problems. percentage success with penetration, degree or intensity of
pain,fear,muscletension,andmedical co-morbidity)butcan
Option 2 be used categorically (see Table 1 for proposed criteria).
A second strategy would be to try to limit or constrain the current Table 1 Proposed diagnostic criteria for Genito-Pelvic Pain/Penetra-
tion Disorder
category in such a way so as to increase diagnostic reliability and
limit clinical variation. For example, women could be diagnosed A. Persistent or recurrent difficulties for 6 months or more with at least
with vaginismus only if they could not currently experience vag- one of the following:
inal penetration in sexual situations, reported fear of (painful) vag- 1. Inability to have vaginal intercourse/penetration on at least 50% of
attempts
inal penetration, and demonstrated behavioral avoidance. Women
2. Marked genito-pelvic pain during at least 50% of vaginal
experiencing any type of pain during penetration would be diag- intercourse/penetration attempts
nosedwithdyspareuniaandthosewithpelvicfloororothermedical
3. Marked fear of vaginal intercourse/penetration or of genito-pelvic
co-morbidity would be diagnosed accordingly. pain during intercourse/penetration on at least 50% of vaginal
This diagnostic strategy avoids the co-morbidity problem intercourse/penetration attempts
with dyspareunia and potentially creates a uniform and easily 4. Marked tensing or tightening of the pelvic floor muscles during
diagnosable category. It is based on ‘‘emerging’’ data suggesting attempted vaginal intercourse/penetration on at least 50% of
occasions
that fear may be a crucial component of what we currently call
B. The disturbance causes marked distress or interpersonal difficulty
vaginismus. Unfortunately, there are no data to show that this
category can be reliably diagnosed. It is also not clear if there are Specify
a significant number of women who meet the relevant criteria With a General Medical Condition (e.g., lichen sclerosis,
endometriosis)
but don’t experience dyspareunia. The category created by this
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286 Arch Sex Behav (2010) 39:278–291
3. It avoids currently unreliable differential diagnoses. current literature and may also require a better definition of life-
4. It is potentially applicable to men who experience penile/ long versus acquired. Anecdotal clinical reports suggest that
pelvic pain during arousal/intercourse/ejaculation (see many women with acquired vaginismus always experienced dys-
Davis, Binik, & Carrier, 2009). pareunia when they were able to have penetration. Ultimately,
5. It provides a guide for adequate assessment that will inform penetration became impossible or too difficult to bear. It is also
treatment. not clear how many successful penetrations with or without pain
would qualify for acquired status.
This diagnostic strategy is not, however, without problems: (1)
a detailed algorithm is necessary to assess each dimension and to
determine what constitutes a threshold level of difficulty; (2) there Is Vaginismus a Sexual Dysfunction?
is no strong evidence yet that some of the dimensions, i.e., pelvic
floor muscle dysfunction, can be reliably assessed; (3) a multi- In principle, the sexual dysfunctions listed in the DSM-III and
disciplinary team is required to complete the full assessment. DSM-IV were defined by their specific interference with one
phase of the ‘‘sexual response cycle.’’ This definition of sexual
dysfunction was a powerful one because it was based on a
Other Issues theoretical model that was empirically supported and provided a
single unifying framework for all sexual dysfunctions. The inclu-
Finally, there seems little reason, regardless of which strategy is sion of the ‘‘sexual pain disorders’’ as sexual dysfunctions was
finally adopted, to retain any of the standard DSM-IV-TR sexual logically problematic for this model and definition since the
dysfunction qualifiers, i.e., lifelong/acquired, global/situational, sexual interference resulting from vaginismus (and dyspareunia)
due to psychological/combined factors. The major reason for was not limited to one phase of the cycle. The sexual response
not retaining these qualifiers is that there is no empirical evi- cycle model has also been challenged on other grounds and it
dence that they have any implications for diagnosis/classifica- seems unlikely that it will survive the DSM-V process. This raises
tion, etiology or treatment outcome. There are other reasons as the important issue of what defines a sexual dysfunction and
well. whether vaginismus should be considered as such.
With respect to the ‘‘global/situational’’ qualifier, there is All the proposed strategies for saving or redefining ‘‘vagi-
very little clinical interest in any situation that doesn’t involve nismus’’ preserve the basic idea that vaginal penetration does
some form of interpersonal sexual penetration. It is possible, in not occur. There is, however, a very long list of reasons that
principle, for a woman to be able to have penile/vaginal pene- could result in vaginal penetration not occurring that would not
tration and not be able to have a gynecological examination or to typically be diagnosed as vaginismus (e.g., lack of interest on the
insert a tampon but this has apparently been reported as a clinical part of the male or female, lack of erection, fear of AIDS, lack of
issue only once (Bollapragada & Melrose, 2008). It may be that a suitable partner, religious concerns, depression, etc.). The pro-
women who can’t experience vaginal penetration in any situa- viso that the woman must ‘‘desire’’ intercourse invokes a vol-
tion are more ‘‘dysfunctional’’ than those who can in some but untary/involuntary criterion that has not been an easy one to
there is no evidence to support this. While with increasing age it operationalize. What is left is the problematic situation of trying
becomes increasingly important to have annual pap smears, to define a problem based on the absence of a behavior (penile
these can often be facilitated by an unhurried and soothing cli- vaginal intercourse or the equivalent) that some would argue
nician using relaxation exercises and, if necessary, medication. should not even be promoted because it is too male oriented.
There are no current methods to distinguish ‘‘due to purely Originally, vaginismus ‘‘belonged’’ to gynecology. The for-
psychological factors’’ from ‘‘due to combined’’ (or ‘‘due to mal diagnostic capability has always remained with gynecology
purely medical factors’’ for that matter). If pain and pelvic floor but even if the muscle tone/strength component were to be pre-
dysfunction are highly co-morbid with vaginismus, then by served, it is not clear that gynecologists are currently trained to
definition most cases will be ‘‘due to combined factors’’ unless make this diagnosis. Since Masters and Johnson (1970), the men-
strategy two above is adopted. Then, all cases would, by defi- tal health professions and sex therapists in particular have con-
nition, be purely psychological unless biological predisposi- firmed the diagnosis and implemented treatment. It is no longer
tions were included. clear who can or should diagnose vaginismus or whether it should
The lifelong/acquired qualifier does make sense in that women be considered a sexual dysfunction. The task of classifying vag-
who have experienced an extended period where vaginal pene- inismus would greatly benefit from an overhauled definition of
tration was possible (acquired) would be expected to be sexually sexual dysfunction.
different from those for whom it was never possible. Unfortu-
Acknowledgments The author is a member of the DSM-V Workgroup
nately, we have not been able to find systematic evidence to sup- on Sexual and Gender Identity Disorders (Chair, Kenneth J. Zucker, Ph.D.).
port this potential difference. Demonstrating such differences I wish to acknowledge the valuable input I received from members of my
may require much larger sample sizes than are typical in the subworkgroup (Lori A. Brotto, Cynthia Graham, and R. Taylor Segraves)
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Arch Sex Behav (2010) 39:278–291 287
and Kenneth J. Zucker. Feedback from DSM-V Work Group Advisors John nosed with genito-pelvic pain/penetration disorder if she has
Bancroft, Sophie Bergeron, Marta Meana, Caroline Pukall, and Leonore never had a partner with an erection sufficient for penetration (or
Tiefer is greatly appreciated as is feedback from Seth Davis, Melissa Far-
mer, Alina Kao, Tuuli Kukkonen, Marie Andrée Lahaie, Caroline Maykut, equivalent forms of penetration). Clinician judgment must of-
Laurel Paterson, and Sabina Sarin. Preliminary versions of the this paper ten be used in determining these exclusion criteria or diagnostic
were presented at the 2009 meetings of the Society for Sex Therapy and thresholds since not all potential diagnostic circumstances can be
Research (Arlington, Virginia, April) and the International Academy of Sex specified. For example, the first dimension (percentage success of
Research (San Juan, Puerto Rico, August). Reprinted with permission from
the Diagnostic and Statistical Manual of Mental Disorders V Workgroup vaginal penetration) requires at least 10 attempts at intercourse in
Reports (Copyright 2009), American Psychiatric Association. the last 6 months before the diagnostic threshold can be reached.
Some women will not have had 10 attempts in the previous
6 months for a variety of reasons (e.g., they and their partner have
‘‘given up trying’’ or they didn’t have a partner for most of this
Appendix: Diagnostic Guidelines for the Assessment period). The clinician can determine whether there have been
of Genito-Pelvic Pain/Penetration Disorder ‘‘sufficient’’ previous attempts to warrant a diagnosis.
The interference questions attempt to determine the de-
Five dimensions are proposed for the assessment and diag- gree of interference related to the dimension. These are not
nosis of genito-pelvic pain/penetration disorder: (1) percent- diagnostic questions but highlight the important finding that
age success of vaginal penetration; (2) pain with vaginal pen- the severity or intensity of a symptom is often not directly
etration; (3) fear of vaginal penetration or of genito-pelvic related to real life interference. For example, some women
pain during vaginal penetration; (4) pelvic floor muscle dys- reporting excruciating vulvar pain may continue to have
function; (5) medical co-morbidity. intercourse/penetration at relative high frequencies.
The description of each dimension includes the following:
(1) proposed assessment questions; (2) diagnostic threshold
criteria; (3) diagnostic exclusion criteria; (4) interference
Dimension 1: Percentage Success of Vaginal Penetration
questions; (5) medical co-morbidity. It is recommended that
a woman who complains of difficulties in experiencing vagi- 1. How many times have you attempted to have intercourse
nal penetration or of pain during sexual intercourse/pene- or penetration in the last 6 months?
tration be assessed on all five dimensions. 2. How many times has there been full penetration into the
The proposed assessment questions are suggested as the vagina during this period?
minimum assessment that any clinician should make for a woman
complaining of difficulties in having vaginal penetration or pain
during intercourse/penetration. All of these questions can be di- Diagnostic Threshold Criteria
rectly asked of the client by a mental health clinician though a full
assessment of pelvic floor muscle dysfunction and medical Must have tried to have vaginal intercourse or penetration at
comorbidity will require a physical examination and expertise least 10 times in the last 6 months and must have failed at
outside of the mental health domain. least 50% of the time.
The diagnostic threshold criteria provide the specifications by
which a clinician can determine that a client is diagnosable with a Diagnostic Exclusion Criteria
genito-pelvic pain/penetration disorder. These thresholds are
based on the available data and the author’s judgment. These 1. Lack of adequate erection (or equivalent types of pene-
thresholds should be modified when new research is available. tration).
To be diagnosed with genito-pelvic pain/penetration disorder, a 2. Has not tried at least 10 times.
client must exceed the threshold for only one of the first four
dimensions. Clients who exceed the threshold for only the fifth
Interference Question
dimension, medical co-morbidity, will be diagnosed with the ap-
propriate medical condition. All dimensions should be assessed
What is the most important reason that you want to have
for all clients even if they are already diagnosable based on one or
sexual intercourse or penetration?
two dimensions because this information will be useful in treat-
ment planning and research. Based on the literature review, it is 1. To get pregnant
quite likely that most clients will exceed diagnostic thresholds for 2. To please my partner
more than one dimension. 3. To have pleasure
The exclusion criteria provide other diagnoses or information 4. To improve our couple relationship
that would exclude a diagnosis of genito-pelvic pain/penetration 5. To improve my sexual self-esteem
disorder. For example, a woman would probably not be diag- 6. Other (specify)
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288 Arch Sex Behav (2010) 39:278–291
Clinician Judgment shooting, stabbing, sharp, cramping, gnawing, hot-burning, ach-

ing, heavy, tender, splitting, tiring-exhausting, sickening, fearful,
The clinician should use his/her judgment in determining punishing-cruel.
whether there have been sufficient attempts at intercourse/pene-
tration during the couple’s relationship. It is possible that these Diagnostic Threshold Criteria
have not occurred in the last 6 months. Judgment must also
be used in interpreting whether ‘‘full penetration’’ has occurred Any reported pain that is directly related to intercourse/pene-
since some women may not know or may indicate ‘‘partial tration and is rated as 3 or 4 should be diagnosed as genito-pelvic
penetration.’’ It is the author’s experience that ‘‘not knowing’’ or pain/penetration disorder.
‘‘partial penetration’’ be interpreted as a failure of penetration
though the final judgment should be made by the clinician. Diagnostic Exclusion Criteria
If there haven’t been an adequate number of attempts based on
the clinician’s judgment and it is believed that that the woman If the client reports several different recurrent or chronic pains in
is ‘‘avoiding intercourse’’ based on fear or other factors, then non-genital areas, then other diagnoses, such as fibromyalgia or
this would be diagnosed under ‘‘the fear of vaginal penetration somatization disorder, might be considered. These diagnoses
or of pain’’ dimension below. can be co-morbid with genito-pelvic pain/penetration disorder.
Dimension 2: Pain with Vaginal Penetration Interference Questions

1. How much pain do you feel pain during (attempted) in- How much does pain interfere with your ability to expe-
tercourse/penetration? rience intercourse/penetration?
How much does pain interfere with your wish to have
0 = No pain
intercourse/penetration?
1 = A little pain
2 = Some pain 0 = Not at all
3 = Moderate pain 1 = A little
4 = Quite a bit of pain 2 = Somewhat
3 = Moderately
2. Could you choose the option which best describes when
4 = Quite a bit or always
you feel the pain (you can choose more than one option
and pain may also occur independently of intercourse/
penetration)? Clinician’s Judgment
1. Before (attempted) intercourse/penetration The clinician must use some judgment in interpreting the
2. At the beginning of (attempted) intercourse/ likely location of the pain since some clients may not be able
penetration to answer this question. Judgment may also be necessary in
3. During thrusting determining how many different pains there are. A superficial
4. During orgasm vulvar pain as well as a deeper pelvic pain may co-occur in
5. After intercourse/penetration is over which case both should be noted and rated separately.
6. During gynecological examinations
7. During tampon insertion
Dimension 3: Fear of Vaginal Penetration or of Genito-
8. While wearing tight pants
Pelvic Pain During Vaginal Penetration
9. While exercising
10. The pain comes and goes and is not related to in- 1. How afraid of, or anxious about, pain do you become
tercourse/penetration when your husband/partner attempts to have intercourse/
11. Other penetration with you?
12. I don’t know (e.g., because I haven’t attempted in-
0 = Not at all
tercourse/penetration in a long time)
1 = A little
3. Looking at the diagram of your genital/pelvic area (see 2 = Somewhat
diagram), can you point to where the pain is (it can be in 3 = Moderately
more than one spot)? 4 = Quite a bit or always
4. How would you describe the quality of your pain?
2. How generally afraid or anxious do you become about things
The examiner can prompt the interviewee based on the adjectives other than pain, when your partner attempts to have inter-
in the short form of the McGill Pain Questionnaire: throbbing, course/penetration with you?
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Arch Sex Behav (2010) 39:278–291 289
0 = Not at all of an average of less than 1 attempt at vaginal intercourse every

1 = A little two months over the past year despite adequate opportunity or
2 = Somewhat being involved in a relationship, and also meeting one of the
3 = Moderately following two criteria (never having seen a health professional
4 = Quite a bit or always for, or never having successfully completed a pelvic exam; never
having used tampons) might be useful in determining if a woman
3. How much do you tense up, in general, when your husband/
is avoiding vaginal penetration.
partner tries to have intercourse/penetration with you?
0 = No tension at all Dimension 4: Pelvic Floor Muscle Dysfunction
1 = A little tension
2 = Some tension How much do the muscles around your vagina tense or tight-
3 = Moderate tension en up when your husband/partner tries to have intercourse/
4 = Quite a bit of tension. penetration with you?
0 = No tension at all
Diagnostic Threshold Criteria 1 = A little tension
2 = Some tension
A rating of 3 or 4 to any of the assessment questions will re- 3 = Moderate tension
sult in a diagnosis of genito-pelvic pain/penetration disorder. 4 = Quite a bit or a lot of tension
Diagnostic Exclusion Criteria

This dimension is designed to reflect a fear of vaginal inter-
How much does this muscle tension (spasm) interfere with
course/penetration or fear of genito-pelvic pain during inter-
your ability to experience intercourse/penetration?
course/penetration. If the client reports generalized anxiety
about all aspects of sexuality or all aspects of social interaction 0 = Not at all
or meets criteria for a generalized anxiety disorder, then alter- 1 = A little
native diagnoses might be more appropriate. These alternative 2 = Somewhat
diagnoses can be comorbid with a diagnosis of genito-pelvic 3 = Moderately
pain/penetration disorder. 4 = Quite a bit or always
Diagnostic Threshold Criteria
How much does fear/anxiety interfere with your ability to
Any rating of 3 or 4 on the interference question would result
have intercourse/penetration?
in a diagnosis of genito-pelvic pain/penetration disorder.
0 = Not at all
1 = A little Exclusion Criteria
2 = Somewhat
3 = Moderately None specified.
4 = Quite a bit or a lot
Clinician Judgment
Clinician Judgment
In this dimension, the interference question is the crucial diag-
nostic one. It has not been typical in the past for women to be asked
The clinician should determine how specific the fear or worry is to
about their genital tension/spasm and it is not clear that there is a
vaginal penetration. Some women will deny any fear/worry but
diagnosable problem if the woman reports tension/spasm but no
will behaviorally avoid any attempts at vaginal penetration by
interference. A full assessment of pelvic floor muscle functioning
closing their legs or turning away during attempted intercourse or
is usually best made a pelvic floor physical therapist.
gynecological examinations. Such avoidance might be reason-
ably interpreted as ‘‘fear/anxiety’’ by the clinician. Such a diag-
Dimension 5: Medical Co-morbidity
nosis can be made based by asking about tampon use, frequen-
cy of gynecological examinations, and frequency of attempted 1. Do you suffer from any medical/physical conditions or take
intercourse/penetration. Reissing et al.’s (2004) research criteria any medications or have you had any surgery that might
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290 Arch Sex Behav (2010) 39:278–291
have caused your difficulties with penetration or your pain

during intercourse? Yes (specify_______________), No,
Don’t Know
2. Have you (ever) had (completed) a (recent) gynecolog-
ical examination? Yes (if yes, when) No
3. Did you tell your gynecologist about your difficulties
with penetration/pain? Yes, No
Diagnostic Threshold Criteria
A mental health professional is not usually in a position to make

a medical/gynecological diagnosis of this kind.
Diagnostic Exclusion Criteria
The existence of a medical condition does not exclude or pre-

clude the diagnosis of genital pain/penetration disorder.
Do you think that there is a physical reason for your pain? Yes
No Don’t Know
Clinician Judgment
Traditional practice has suggested that physical causes be ex-

cluded before psychological diagnoses are made. This model
may no longer be appropriate for genital pain/penetration dis-
order. In fact, it is often impossible to determine with any degree
of certainty whether there is or how much basis there is for
physical causation. Current pain assessment strategies empha-
size multidisciplinary and biopsychosocial models. Prudent cur-
rent practice for women complaining of genito-pelvic pain/
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DOI 10.1007/s10508-009-9563-x
ORIGINAL PAPER
The DSM Diagnostic Criteria for Dyspareunia

Yitzchak M. Binik

Abstract The DSM-IV-TR attempted to create a unitary cat- vaginismus under the heading of ‘‘sexual pain disorders’’ and is
egory of dyspareunia based on the criterion of genital pain that defined as follows:
interfered with sexual intercourse. This classificatory emphasis of
A. Recurrent or persistent genital pain associated with sexual
interference with intercourse is reviewed and evaluated from both
intercourse in either a male or a female.
theoretical and empirical points of view. Neither of these points of
B. The disturbance causes marked distress or interpersonal
view was found to support the notion of dyspareunia as a unitary
difficulty.
disorder or its inclusion in the DSM-V as a sexual dysfunction. It
C. The disturbance is not caused exclusively by Vaginismus
seems highly likely that there are different syndromes of dyspa-
or lack of lubrication, is not better accounted for by another
reunia and that what is currently termed ‘‘superficial dyspareu-
Axis 1 disorder (except another Sexual Dysfunction) and is
nia’’ cannot be differentiated reliably from vaginismus. It is pro-
not due exclusively to the direct physiological effects of a
posed that the diagnoses of vaginismus and dyspareunia be col-
substance (e.g., a drug of abuse, a medication) or a general
lapsed into a single diagnostic entity called genito-pelvic pain/
medical condition. (p. 556)
penetration disorder. This diagnostic category is defined accord-
ing to five dimensions: percentage success of vaginal penetration; As with all DSM-IV-TR (American Psychiatric Association,
pain with vaginal penetration; fear of vaginal penetration or of 2000) sexual dysfunctions, the specifiers of ‘‘lifelong/acquired,’’
genito-pelvic pain during vaginal penetration; pelvic floor muscle ‘‘generalized/situational,’’ and ‘‘due to psychological factors/due
dysfunction; medical co-morbidity. to combined factors’’ are used to qualify this diagnosis. If dys-
pareunia is judged to be the exclusive result of medical factors or
Keywords Dyspareunia Vaginismus Vulvodynia the exclusive and direct result oftaking a medication orsubstance,
Vestibulodynia Pelvic pain DSM-V then ‘‘sexual dysfunction due to a general medical condition’’ or
‘‘substance-induced sexual dysfunction’’ is diagnosed.
Introduction
History of the Classification of Dyspareunia
Dyspareunia is classified as a sexual dysfunction in the Diag-
nostic and Statistical Manual of Mental Disorders (DSM-IV- The problem of pain during sexual intercourse has been rec-
TR; American Psychiatric Association, 2000). It is grouped with ognized for at least 3000 years. For example, the Ramesseum
Papyri (Barnes, 1956) linked vulvar pain during intercourse
to menstrual pain and irregularity. This traditional linking of all
Y. M. Binik (&)
Department of Psychology, McGill University, 1205 Dr. Penfield women’s problems to the uterus and menstruation was ap-
Avenue, Montreal, QC H3A 1B1, Canada parently rejected by Soranus of Ephesus, a Roman physician,
e-mail: [email protected] who described a localized vulvar condition causing pain during
intercourse (McElhiney, Kelly, Rosen, & Bachmann, 2006).
Y. M. Binik
Sex and Couple Therapy Service, McGill University Health Today, this condition would probably be called vulvodynia.
Center, Montreal, QC, Canada Another approach was taken by Hildanus, a 16th century Euro-
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Arch Sex Behav (2010) 39:292–303 293
pean surgeon, who ascribed some cases of dyspareunia to mis- hoc consensus has resulted in research and clinical literatures
matched anatomies resulting from disproportionately long pe- that discuss de facto subtypes of dyspareunia, such as ‘‘super-
nises. He developed a ‘‘device’’ to solve this problem (Ko- ficial,’’ ‘‘deep,’’ ‘‘post-partum,’’ ‘‘post-menopausal,’’ ‘‘due to
mpanje, 2006). The term ‘‘dyspareunia’’ (i.e., difficult mating) vulvar vestibulitis,’’ etc. The DSM-IV-TR (American Psy-
was coined by Barnes in 1874, who suggested that there were chiatric Association, 2000) does not directly deal with this
multiple physical pathologies that could cause such pain. He issue but presumes that any genital pain provoked by inter-
focused, however, on the presenting clinical complaint of in- course that is not medically caused should be diagnosed as
terference with intercourse rather than on the possible pathol- dyspareunia. One troubling diagnostic outcome of this strat-
ogies or symptoms as the way to describe this problem. egy is that, in the absence of ‘‘general medical conditions,’’
In the early 20th century, under the influence of the psy- a woman who experiences a shooting pain over one ovary
choanalytic movement, dyspareunia returned to being consid- during thrusting and one who experiences a burning pain at
ered a ‘‘hysterical’’ symptom. Interest in physical pathologies the introitus during penetration could both be classified as
waned and treatment focused on psychosexual issues. This was suffering from dyspareunia. Although both women may
not inconsistent with Barnes’ (1874) emphasis on interference experience interference with intercourse, this commonality
with intercourse and may have paved the way for the DSM- does not suggest the same diagnosis for many clinicians and
III (American Psychiatric Association, 1980) to classify dyspa- highlights the issue of whether the DSM-IV-TR’s focus on an
reunia as a sexual problem. This classification was preserved interference with intercourse criterion as the unifying char-
by the DSM-III-R (American Psychiatric Association, 1987), acteristic for the definition of ‘‘dyspareunia’’ is valid.
which introduced the subcategory of ‘‘sexual pain disorder’’ and
grouped dyspareunia with vaginismus in this subcategory. The Should Dyspareunia be Classified by Etiology
conceptualization of dyspareunia as a sexual dysfunction with or by Symptom?
the attendant emphasis on interference with intercourse remains
in the DSM-IV-TR (American Psychiatric Association, 2000) The issue of whether there are different types (or syndromes) of
and also exists in the ICD-10 (World Health Organization, dyspareunia is closely related to whether dyspareunia should be
1992), where it is termed ‘‘nonorganic dyspareunia’’ (F52.6, classified by etiology or by symptom. An etiologically based
p. 356). A text note in the ICD-10 suggests that dyspareu- approach would attempt to classify dyspareunia based on pre-
nia ‘‘…can often be attributed to local pathology and should sumed or demonstrated cause while a symptom-based one ig-
then properly be categorized under the pathological condition’’ nores cause and classifies based on different clinical manifes-
(p. 356). This refers to another ICD-10 category of ‘‘organic tations. Although the DSM-IV-TR officially espouses a symp-
dyspareunia’’ (N94.1, p. 717), listed in the section entitled ‘‘Pain tom-based classification system, in practice, it includes ele-
and other conditions associated with female genital organs and ments of both etiologically and symptom-based approaches in
menstrual cycle’’ (N94, p. 717). its classification of dyspareunia (and all sexual dysfunctions).
This brief historical review highlights very different ap- The clinician is initially forced into an etiological classification
proaches to the conceptualization of dyspareunia. Most of and asked to determine whether dyspareunia is caused by ex-
these approaches are still in evidence in the modern literature. clusively medical, exclusively psychological or mixed factors.
This review also highlights the following theoretical and log- Unfortunately, there are no tools or criteria listed which might
ical problems: (1) Is dyspareunia a unitary diagnostic cate- help with such a decision for dyspareunia other than a list of
gory or a hodgepodge of different syndromes all of which in- general medical conditions (‘‘…insufficient vaginal lubrication;
terfere with intercourse? (2) Should dyspareunia be classified pelvic pathology such as vaginal or urinary tract infections,
by etiology or by symptom? (3) Is dyspareunia a sexual dys- vaginal scar tissue, endometriosis, or adhesions; postmeno-
function? My discussion of the meager diagnostic empirical pausal vaginal atrophy; temporary estrogen deprivation during
literature will be prefaced by a consideration of these the- lactation; urinary tract irritation or infection; or gastrointestinal
oretical/logical issues. conditions’’; American Psychiatric Association, 2000, p. 555).
Most mental health professionals cannot make such etiologi-
cally based diagnoses and it is dubious whether categories such
Theoretical and Logical Issues in the Classification as exclusively medical, psychological or mixed are valid.
of Dyspareunia Once the initial etiological distinction (exclusively medical,
exclusively psychological, mixed) is made for dyspareunia,
Is Dyspareunia a Unitary Diagnostic Category? then the major symptom of interest for the DSM-IV-TR is gen-
ital pain provoked by intercourse. However, a typical symp-
Most clinicians and researchers today would probably agree tom-based classification focuses on the characteristics of the
with the statement that there appear to be different types of central pain symptom (e.g., intensity, location, quality, duration,
or different syndromes that result in dyspareunia. This ad etc.) but does not usually focus on the activity interfered with.
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294 Arch Sex Behav (2010) 39:292–303
One would not classify headache based on whether it interferes been ‘‘pain disorder’’ rather than sexual dysfunction. Despite
with work or sex. There seems little reason to classify genital this logic, dyspareunia was specifically excluded as a pain dis-
pain this way. Why this was not done for dyspareunia in the order in the DSM-IV-TR (American Psychiatric Association,
DSM-IV-TR is unclear. 2000, p. 503). This decision was never explicitly rationalized in
In fact, etiologically and symptom-based classifications can the DSM-IV Sourcebooks (e.g., Schmidt, Schiavi, Schover,
be combined in various ways. An interesting example is the Segraves, & Wise, 1998); however, it was presumably based on
International Classification of Headache Disorders (Olesen, tradition, hypothesized sexual etiologies for dyspareunia (e.g.,
2004), which consists of a hierarchical classification in which reduced arousal), and the fact that provoked genital pain typi-
primary headaches (e.g., migraine, tension, cluster) are typically becomes a clinical issue only by virtue of its interference
cally diagnosed symptomatically; however, a secondary cat- with intercourse.
egory of headaches ‘‘attributed’’ to relatively well established In a target article followed by peer commentary, Binik
causes also exists. Other pain syndromes are typically classi- (2005a) proposed that dyspareunia be re-conceptualized as a
fied similarly (Merskey & Bogduk, 1994). pain disorder rather than a sexual dysfunction. He supported this
If such an approach is applied to dyspareunia, then this type proposal by arguing that genito-pelvic pain was the main symp-
of pain potentially becomes a type of genito-pelvic pain. The tom. Second, he argued that diagnostic classifications are not
International Society for the Study of Vulvar Disease (ISSVD) usually constructed based on the activities the disorders inter-
has recently published a classification of vulvar pain (Moyal- fered with. Third, he suggested that the term ‘‘sexual pain’’ was
Barracco & Lynch, 2004) which suggests two major categories: faulty because it implied that there is a special type of pain linked
(1) vulvar pain related to a specific disorder; (2) vulvodynia (i.e., to sexual intercourse. In fact, the pain of dyspareunia can typi-
unrelated to a specific disorder). Vulvodynia is subclassified cally be reproduced in non-sexual situations, such as tampon in-
into ‘‘generalized’’ (i.e., pain occurring in the whole vulva) or sertion, gynecological examination, sports, wearing tight cloth-
‘‘localized’’ (i.e., pain occurring in a specific area, such as the ing, etc. In addition, many women suffering from dyspareunia
vestibule or the clitoris). In addition, the classification divides report genito-pelvic pain at ‘‘pre-sexual/intercourse’’ ages, i.e.,
vulvodynia into provoked (i.e., triggered) or unprovoked (i.e., from the time they first attempt to insert a tampon (Landry &
spontaneous) pain. In this classification, vulvar pain provoked Bergeron, 2009). Finally, Binik (2005a) argued that the sexual
by intercourse is what would be termed dyspareunia by the dysfunction classification in the DSM-IV-TR was based on
DSM. This classification does imply that some types of vulvar disruptions of the sexual response cycle (desire, arousal, orgasm).
pain are ‘‘organic’’ or ‘‘related to a specific disorder’’ but focuses Dyspareunia does not really fit into this conceptualization and, in
on the anatomical location of pain. Similar classification ini- fact, disrupts all aspects of sexual response.
tiatives are being undertaken by professional groups interested Most of the respondents to this target article (Binik, 2005a)
in deep dyspareunia (Abrams et al., 2006; Fall et al., 2004). did not support Binik’s reclassification proposal. They sug-
The provoked/unprovoked distinction for vulvar pain raises gested that most of the supporting empirical research cited by
another important classification issue. The interference with Binik was limited to one type of dyspareunia, provoked ves-
intercourse criterion has focused mental health clinicians on tibulodynia (PVD, formerly known as vulvar vestibulitis syn-
women who experience only provoked genito-pelvic pain. In drome or VVS) and, therefore, could not be generalized to dys-
fact, there are women who experience unprovoked genito- pareunia in general. They also pointed out that pain research-
pelvic pain but also experience pain provoked by intercourse ers and clinicians had little experience or interest in dyspareunia
as well as women who experience unprovoked pain but no pain and, therefore, reclassification would be of dubious clinical
specifically related to intercourse. It is not apparent whether utility. Finally, they maintained that symptom-based classifi-
these different symptom patterns are all subtypes of one dis- cations are inferior to etiologically-based ones and that dyspa-
order or different ones. reunia does, in fact, meet the criteria for a sexual dysfunction.
Although Binik (2005b) acknowledged the validity of these
criticisms, he suggested the following: (1) there is no reason to
Is Dyspareunia a Sexual Dysfunction? think that other dyspareunia syndromes would be essentially
different from PVD; (2) reclassification would encourage pain
The defining symptom of dyspareunia is the self-report of ge- clinicians to get involved without excluding sexologists; (3) eti-
nito-pelvic pain during sexual intercourse. Because the pain typologically-based definitions of sexual dysfunction are not im-
ically interferes with sexual intercourse, dyspareunia has been minent but when there are sufficient data to support these for
traditionally classified as a sexual dysfunction. Usually, how- dyspareunia, then they could supplant a pain symptom based
ever, symptom-based classifications rely on the primary symp- classification; (4) current definitions of sexual dysfunction
tom rather than the activity interfered with as the basis for classi- based on the sexual response cycle are outmoded and, in
fication. The resulting ‘‘logical’’ DSM category would have any case, dyspareunia does not fit into this cycle.
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Miscellaneous Issues symptom reports can be based either on patient self-report

of genito-pelvic pain provoked by intercourse, gynecologi-
There are a number of other theoretical/logical issues that are cal examination, or other activities (e.g., tampon insertion,
relevant to the DSM-IV-TR definition of dyspareunia. Some of sports, wearing tight clothing, etc.) or on the report of spon-
these issues plague all sexual dysfunction diagnoses. For exam- taneous or unprovoked genito-pelvic pain. The existing pat-
ple, there is no specification of how frequent or recurrent pain terns of self-reported genito-pelvic pain can also be com-
during intercourse must be to merit a diagnosis. In the associated bined with the results of standard gynecological examina-
text, it states the following: ‘‘Occasional pain associated with tions, laboratory cultures, or specialized tests such as vaginal
sexual intercourse that is not persistent or recurrent…is not con- ultrasound, colposcopy or laparoscopy.
sidered to be Dyspareunia’’ (American Psychiatric Association, There appear to be only two studies that attempted to in-
2000, p. 556). Unfortunately, there is no definition of ‘‘occa- vestigate dyspareunia in this way (Danielsson, 2001; Meana,
sional.’’ There is also no specification of the intensity of the pain. Binik, Khalifé, & Cohen, 1997).The general strategy employed
The associated text, entitled ‘‘Diagnostic Features’’ (p. 554), in these studies is to recruit relatively unscreened samples of
states that ‘‘The intensity of the symptoms may range from mild women complaining of dyspareunia and to attempt to classify
discomfort to sharp pain.’’ This is very vague and it would seem them into subgroups based on pain symptom reports, laboratory
that some minimal threshold of pain or discomfort should be cultures, and gynecological examinations and tests.
specified for diagnostic purposes. Finally, the diagnosis of Meana et al. (1997) were able to classify their sample of 112
dyspareunia is applied to both men and women. There is, dyspareunic women into the following four major subgroups:
however, no discussion of male dyspareunia in the DSM-IV- (1) PVD (aka vulvar vestibulitis syndrome); (2) vulvovaginal
TR. Until recently, this problem was thought to be relatively atrophy; (3) dyspareunia unrelated to physical findings; (4) mix-
rare; recent research, however, has suggested that this may not ed (mostly deep dyspareunia). Danielsson’s (2001) study based
be the case (Davis, Binik, & Carrier, 2009). Moreover, the exist- on 64 women resulted in similar subgroups, which were named
ing cases of male dyspareunia were often attributed to inflam- as follows: (1) PVD; (2) vulvovaginal atrophy; (3) mixed dys-
mation of the prostate and referred to urologists for medical pareunia; (4) deep dyspareunia.
treatment. This diagnosis of prostatitis has been called into ques- Overall, these results suggest that what is currently called
tion and is now typically referred to as chronic pelvic pain syn- dyspareunia might be usefully divided into several types, in-
drome in men. This literature has recently been reviewed by cluding PVD, vulvovaginal atrophy, and deep dyspareunia.
Davis et al. and will not be further discussed here. Since both PVD and vulvovaginal atrophy can be charac-
terized as superficial, it seems that one initial way to divide
dyspareunia is between superficial and deep types. There may
Empirical Studies of the Diagnosis of Dyspareunia also be at least two subtypes of superficial dyspareunia, i.e.,
PVD and vulvovaginal atrophy. The concordance in results
There has been very little empirical diagnostic research con- between the Meana et al. (1997) and Danielsson (2001)
cerning dyspareunia. This situation probably reflects, to some studies is striking and appears to support a symptom-based
extent, the conceptual and interdisciplinary confusion discussed approach to classifying dyspareunia. This conclusion may be
above. There are, however, a few empirical studies addressing premature, however, since both studies used relatively small
the issue of whether dyspareunia is a unitary diagnostic cate- convenience samples and one study is unpublished. Further-
gory. Traditional diagnostic reliability studies almost do not ex- more, neither study appears to acknowledge the possibility of
ist but there is small empirical differential diagnosis literature at- comorbidity between superficial and deep dyspareunia (Puk-
tempting to validate the existence of dyspareunia (usually PVD) all & Binik, 2009). Most important, perhaps, is that neither
as distinct from vaginismus. Finally, there is a small etiologi- study used a ‘‘pure’’ patient–reported, symptom-based clas-
cally based diagnostic literature concerning deep dyspareunia. sification approach. Instead, they combined and differen-
tially weighted patient symptom reports with physical exam-
Are There Dyspareunia Subtypes? ination impressions and laboratory culture results in order to
create dyspareunia subgroups. It is not clear, a priori, how to
One empirical strategy for investigating this issue is to exam- combine and statistically weight these very different kinds
ine whether the disorder that DSM-IV-TR defines as dyspa- of data.
reunia can be usefully broken down into smaller categories The difficulties in dealing with such data from women suf-
either based on symptom self-reports or other data. This fering from dyspareunia are illustrated by the fact that the
method has been very successfully utilized in the study of symptom-based pain reports of premenopausal women suf-
headache where there are now established syndromes (e.g., fering from PVD and those of postmenopausal women with
tension, cluster, migraine) primarily based on self-reported vulvovaginal atrophy appear to be very similar (Kao, Binik,
pain symptoms (Olesen, 2004). With respect to dyspareunia, Khalifé et al., 2008). A pure symptom-based approach would
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296 Arch Sex Behav (2010) 39:292–303
likely classify these women together, ignoring the age, hor- criteria: (1) severe pain on vestibular touch or attempted vaginal
monal, and vulvovaginal atrophy differences. Most gynecol- entry; (2) tenderness to pressure localized within the vulvar ves-
ogists, however, focus on the age-related biological differen- tibule; (3) physical findings confined to vestibular erythema.
ces even though the causal chain that links reduced estrogen In practice, women complaining of all types of superficial
levels associated with menopause to vulvovaginal atrophy genital pain during intercourse are usually directed to a gyne-
and dyspareunia has not been well-established empirically cologist who will perform a standard examination. If PVD is
(Kao, Binik, Kapuscinski, & Khalifé, 2008). Although the suspected, the gynecologist will typically use the cotton swab
Meana et al. (1997) and Danielsson (2001) studies both con- (Q-tip) test to confirm the diagnosis. In this examination, a gyne-
clude that there is a separate category of post-menopausal cologist palpates the labia and vulva with a cotton swab. Wom-
dyspareunia, this appears to have been primarily determined en are diagnosed with PVD by a gynecologist if they report
by gynecologist opinion rather than symptom report. This is- significant pain during cotton swab palpation that is limited to
sue is further complicated by the fact that the reliability of the the vulvar vestibule and if there are no known physical causes,
diagnosis of vulvovaginal atrophy has not been rigorously with the possible exception of non-specific inflammation. PVD
tested (Kao, Binik, Kapuscinski et al., 2008). That there was is, therefore, a diagnosis of exclusion, in part, and different gyne-
only one participating gynecologist in the Meana et al. (1997) cologists vary in the number and extent of examinations and tests
and Danielsson (2001) studies makes it difficult to determine they will perform to exclude potential physical causes.
whether the diagnosis of vulvovaginal atrophy was accurate
or whether the gynecologists were simply influenced by the Can the Diagnosis of Provoked Vestibulodynia
obvious age differences of the patients. Be Made Reliably?
Overall, the existing data suggest that future empirical stud-
ies should continue to examine potential dyspareunia subtypes The cotton swab diagnostic test for PVD appears to be pro-
while making explicit how the different types of data are used cedurally simple and easily replicable, suggesting that the di-
and combined. Since the existing diagnostic research separates agnosis of PVD is reliable. Research in our laboratory (e.g.,
superficial from deep dyspareunia and the existing data sup- Bergeron, Binik, Khalifé, Pagidas, & Glazer, 2001) has sug-
port this differentiation, these literatures will be separately re- gested that there is much variation in how gynecological
viewed. examinations are performed, in general, and how the cotton
swab test is performed specifically. For example, some gyne-
cologists push the cotton swab once firmly into each area to be
Superficial Dyspareunia
palpated and, if there is pain, wait until it subsides before the
next palpation; others palpate repeatedly in the same area
In the last 15 years, there has been a renewed empirical interest
with few pauses, even if there is pain; others do not push at all,
in the study of ‘‘superficial’’ dyspareunia (Goldstein, Pukall, &
but roll the swab around the vestibule. How many spots are
Goldstein, 2009). Although the majority of this research has
palpated and in which order has never been standardized.
focused on PVD, superficial dyspareunia also includes any type
From a sensory point of view, different forms of stimulation
of recurrent pain felt in the vulvovaginal area during intercourse.
with varying amounts of pressure are being applied during the
In principle, such dyspareunia could be associated with very
cotton swab test and this is highly likely to result in different
different ‘‘conditions,’’ ranging from inadequate arousal to li-
pain experiences and reports. From an interpersonal perspec-
chen sclerosis. Current classifications of vulvar pain and most
tive, a regular gynecological examination is a complex and
expert opinions (see ISSVD classification reviewed above) sug-
sometimes stressful experience for many women that can
gest that there are multiple possible types or syndromes of such
easily be further complicated by the expectation or experi-
pain. Nonetheless, most of the available studies examine the di-
ence of pain. What the gynecologist does, says, or how he/
agnosis of PVD or whether PVD can be differentiated from
she interacts with the patient can potentially have a dramat-
other types of vulvodynia or from vaginismus.
ic influence on pain reports (Huber, Pukall, Boyer, Reissing,
& Chamberlain, 2009).
What is Provoked Vestibulodynia (PVD) and How There have been only two studies examining the reliability
Is It Typically Diagnosed? of the diagnosis of PVD (Bergeron et al., 2001; Masheb, Loz-
ano, Richman, Minkin, & Kerns, 2004). In the Bergeron et al.
PVD is typically described as a burning or cutting type pain study, two gynecologists examined 146 women complaining
localized to the vulvar vestibule and provoked by mechanical of dyspareunia according to a standardized protocol which
stimulation (e.g., intercourse). It is considered to be the most fre- included the following: (1) urine sample; (2) brief symptom
quent pattern of pre-menopausal dyspareunia. Although PVD history interview; (3) vaginal cultures; (4) cotton swab pal-
was described in the 19th century, this diagnosis was ignored pation; (5) assessment of vestibular erythema; (6) standard
until Friedrich (1987) defined it according to the following bimanual palpation of vagina, uterus, and adnexae. Patients
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Arch Sex Behav (2010) 39:292–303 297
were asked to rate pain intensity on a 0–10 scale during the of pain during intercourse provide reliable diagnostic infor-
cotton swab test and during palpation of labia majora and mation?
labia minora (right, left, and midline) and six vestibular sites
(in a clockwise fashion; 12, then 12–3, 3–6, 6, 6–9, and 9–12 Can/Should a Diagnosis of Provoked Vestibulodynia
o’clock). This procedure was repeated for all the patients 6 Be Made Without a Gynecological Examination?
weeks later after a baseline period during which there was no
treatment. Anecdotal clinical reports and the available data (e.g., Meana
The gynecologists were instructed to use Friedrich’s (1987) et al., 1997) suggest that most younger women seeking clinical
criteria in order to make a diagnosis of PVD. Average per- attention for superficial dyspareunia have no physical findings
centage agreement for the two gynecologists making the diag- and fit the pattern currently diagnosed as PVD. Some women,
nosis of PVD was over 90%, yielding average Kappa values however, are unable to describe or locate the pain they experi-
from .66 to .68. In terms of test–retest reliability, the percentage ence during intercourse. There are also a number of conditions
agreements between Time 1 and Time 2 for each of the gyne- and pathological states other than PVD that result in superfi-
cologists were 96.7% (Kappa = .49) and 93.9% (Kappa = cial dyspareunia which may be hard to distinguish from PVD
.54), respectively. (Foster, 2002). Although it does appear that epidemiological
This study also yielded other important diagnostic informa- surveys can identify many of these women, additional infor-
tion: (1) approximately 90% of the women diagnosed with PVD mation and particularly a gynecological examination with a
used thermal or incisive adjectives to describe their pain; (2) cotton swab and other appropriate tests appears necessary to
there was a normally distributed range of pain intensity ratings differentiate PVD from these conditions (Harlow & Stewart,
given by women during the cotton swab test; (3) erythema rat- 2005; Masheb, Lozano et al., 2004; Reed, Crawford, Couper,
ings by gynecologists were not reliable diagnostic indicators; Cave, & Haefner, 2004; Reed, Haefner, Harlow, Gorenflo, &
(4) pain was limited to the vulvar vestibule; (5) one gynecolo- Sen, 2006).
gist, on average, elicited significantly higher pain ratings than
the other; (6) the correlations between patients’ vestibular pain Can Self-Report of Pain During the Cotton Swab Test
ratings during gynecological examinations and their reported (Sensory Testing) of the Genitalia Provide Reliable
pain during intercourse were significant but small (r = .28, Diagnostic Information?
p \ .01) for one gynecologist and non-significant for the other
(r = .04). Quantitative sensory testing, based on traditional psychophys-
In the Masheb, Lozano et al. (2004) study, two gynecologists ical methodology, has long been used as a diagnostic method for
independently examined 50 women diagnosed with either PVD pain patients (Lautenbacher & Fillingim, 2004). In general, this
or dysesthetic vulvodynia. Overall, their findings tended to con- methodology applies controlled stimuli (e.g., pressure, tem-
firm those of Bergeron et al. (2001) and showed that patient- perature, vibration) to painful and non-painful body areas in an
reported pain ratings elicited during the cotton swab test were attempt to characterize the nature and extent of the pain or sen-
reliable while gynecologist-rated erythema was not. In addition, sory variation. Typically, touch or pain detection or pain toler-
physician ratings of patient pain during speculum insertion were ance thresholds are tested under controlled conditions. From a
found to be reliable. clinical point of view, the goals of such testing would include the
Overall, these studies suggest that the diagnosis of PVD can provision of a sensitive and specific test to distinguish patients
be made reliably though it appears that a significant amount of from controls, to differentiate patient subgroups, and to track
gynecologist training in order to standardize examination pro- treatment progress. In effect, the cotton swab diagnostic test for
cedures is necessary in order to insure this. It also appears nec- PVD is a crude type of sensory testing. Recently, there have
essary for the gynecologists to agree on a single classification been numerous attempts to improve the sensitivity of the cotton
system, such as that proposed by the ISSVD (Moyal-Barracco swab test by developing instruments with which the sensory
& Lynch, 2004), because it appears that there is a significant stimulation can be more closely controlled and quantified.
amount of symptomatic overlap between the diagnosis of PVD The vulvalgesiometer is one such instrument that is very
and other forms of vulvodynia (Edwards, 2004; Masheb, Loz- similar to the original gynecological test because it employs a
ano-Blanco, Kohorn, Minkin, & Kerns, 2004; Reed, Gorenflo, series of spring-controlled disposable cotton swabs as the stim-
& Haefner, 2003). ulating device (Pukall, Young, Roberts, Sutton, & Smith, 2007).
These studies also raise the following important questions for There are, however, at least several other instruments, including
the diagnosis of PVD and for the diagnosis of dyspareunia, in a vaginal algometer (Baguley, Curnow, Morrison, & Barron,
general: (1) Can/should a diagnosis of PVD (dyspareunia) be 2003), a vulvodolorimeter (Giesecke et al., 2004), a pressure
made without a gynecological examination? (2) Can self-report algometer (Tu, Fitzgerald, Kuiken, Farrell, & Norman Harden,
of pain during cotton swab (sensory) testing of the genitalia 2008), and an algesiometer (Eva, Reid, MacLean, & Morrison,
provide reliable diagnostic information? (3) Can the self-report 1999) that have been developed. These instruments all test
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298 Arch Sex Behav (2010) 39:292–303
pressure or mechanical sensitivity but research has also been number of self-administered sexual functioning measures, such
conducted with thermal and vibratory stimuli (e.g., Bohm- as the Changes in Sexual Functioning Questionnaire (CSFQ)
Starke, Hilliges, Brodda-Jansen, Rylander, & Torebjork, 2001; (Clayton, McGarvey, & Clavet, 1997; Clayton, McGarvey,
Granot, Zimmer, Friedman, Lowenstein, & Yarnitsky, 2004; Clavet, & Piazza, 1997), the Golombok-Rust Inventory of
Lowenstein et al., 2004; Zolnoun, Lamvu, & Steege, 2008). One Sexual Satisfaction (GRISS) (Rust & Golombok, 1998), the
criticism of this approach is that the nature of the sensory stimu- McCoy Female Sexuality Questionnaire (MFSQ) (McCoy &
lation tested often does not closely replicate the experienced Matyas, 1998), and the Brief Index of Sexual Functioning for
sensory stimulation during vaginal intercourse and, therefore, Women (BISF-W) (Taylor, Rosen, & Leiblum, 1994), contain
cannot be a sensitive diagnostic measure for the real life situa- one question to assess the existence and frequency of pain with
tion of clinical importance. Foster et al. (2009) have recently intercourse. These single items are not sufficient for diagnostic
suggested a tampon test which may more closely replicate the purposes. Other standardized questionnaires, such as the Sexual
sensory aspects of penile penetration than the punctate pressure Function Questionnaire (SFQ) (Quirk, Haughie, & Symonds,
provided by other methods. Another, perhaps more important, 2005; Quirk et al., 2002) and the Female Sexual Functioning
criticism of sensory testing is that the interpersonal and intimate Index (FSFI) (Rosen et al., 2000), have several questions related
nature of sexual intercourse strongly suggests that it is more than to the frequency and intensity of pain during intercourse. There
sensory stimulation that determines pain in this situation. Recent is promising but preliminary validation data concerning the
research concerning the interpersonal determinants of pain ability of the FSFI to diagnose dyspareunia (Masheb, Lozano-
experienced during intercourse is beginning to confirm this Blanco et al., 2004; Verit & Verit, 2007). The development of
view (Desrosiers et al., 2008). Both the methodological and reliable and valid self-report measures for PVD and dyspareunia
interpersonal critiques of sensory testing are reflected in the in general is necessary.
reported variable correlations between such laboratory mea-
sures and self-rated pain during intercourse (e.g., Bohm-Starke, Differential Diagnosis of Dyspareunia and Vaginismus
Brodda-Jansen, Linder, & Danielsson, 2007). The variation in
these correlations is also increased by small but significant groups Dyspareunia and vaginismus are grouped together in the DSM-
of women who either respond with significant pain during sen- IV-TR under the heading of ‘‘sexual pain disorders.’’ This
sory testing but not during intercourse or who experience little grouping suggests that these disorders were considered by the
or no pain during sensory testing but report significant pain dur- writers of the DSM to be more similar to each other than they
ing intercourse. were to the other sexual dysfunctions. On the other hand, the di-
A recent general review of the clinical relevance of quanti- agnostic criteria and associated text make it clear that they are
tative sensory testing for all pain problems concluded that it has considered distinct disorders and prohibits comorbid diagnoses
great potential that has not yet been realized (Edwards, Sarlani, of vaginismus and dyspareunia. In practice, however, it is often
Wesselmann, & Fillingim, 2005). This conclusion seems appro- problematic for clinicians to differentiate these two disorders
priate for the PVD literature in which the gynecological cotton since patients often present with features of both. In fact, there
swab test is the clinical norm for diagnosis. There is no empirical are a number of studies that have attempted and failed to dif-
or clinical diagnostic literature on quantitative sensory testing ferentiate vaginismus from dyspareunia based on different cri-
for other forms of superficial dyspareunia but, in principle, there teria including muscle tension/spasm, pain, fear/distress and
is no reason to assume that this could not be achieved. What is self-reported behavior. These studies are examined in detail
lacking at the moment is adequate standardization and sufficient in the diagnostic review of vaginismus (Binik, 2009). Overall,
numbers to determine whether quantitative sensory testing will there is no current empirical evidence that dyspareunia can be
remain an important research laboratory tool or whether it can reliably differentiated from vaginismus.
also become a clinical diagnostic one.
Deep Dyspareunia
Can Standardized Self-Report Instruments Provide
Reliable Diagnostic Information? The standard clinical approach (American College of Obste-
tricians and Gynecologists; see Ferrero, Ragni, & Remorgida,
None of the current standardized clinical diagnostic interviews, 2008; Howard, 2004) to deep dyspareunia has been to etiolog-
such as the Structured Clinical Interview for DSM-IV (First & ically link it to an underlying disease or pathology. A partial list
Gibbon, 2004) or the Diagnostic Interview Schedule (Compton might typically include endometriosis, pelvic congestion syn-
& Cottler, 2004), have sections related to sexual dysfunction; as drome, levator ani muscle myalgia, uterine retroversion, uterine
a result, there is no relevant information concerning the reli- myomas, adenomyosis, ovarian remnant syndrome, irritable
ability or validity of this method for diagnosing dyspareunia. In bowel syndrome, etc. In addition, for a significant number of
a comprehensive review of self-report instruments for sexual women, deep dyspareunia is accompanied by dysmenorrhea,
dysfunction, Meana, Binik, and Thaler (2008) pointed out that a bladder/urinary or gastrointestinal symptoms. This often leads
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Arch Sex Behav (2010) 39:292–303 299
to diagnoses such as interstitial cystitis or pelvic inflamma- are considered to cause deep dyspareunia but there is rarely any
tory disease rather than dyspareunia since these other types of diagnostic concern with the dyspareunia per se, since it is tra-
symptoms may be considered primary. A large percentage of ditionally considered only a symptom of the underlying disease.
women experiencing deep dyspareunia also experience very One possible exception to this generalization is the recent pop-
similar pain ‘‘spontaneously’’ or in non-intercourse related sit- ularity of ‘‘conscious laparoscopic pain mapping’’ (Almeida &
uations. This high degree of co-occurrence between intercourse Val-Gallas, 1997). This procedure is similar to standard lap-
and non-intercourse-related deep genito-pelvic pain has sup- aroscopy except that it is done under local anesthesia with the
ported the view that both the deep dyspareunia and the non- patient sedated but conscious. This potentially allows the patient
intercourse-related pain are closely related and probably the to report to the examiner pain sources that may be referred or
result of a disease or pathological condition. Even if no under- may not be obvious. Unfortunately, there is no strong evidence
lying disease/pathology is found, then a diagnosis of dyspareu- to suggest that conscious laparoscopic pain mapping has im-
nia is rarely given. A more typical diagnosis would be ‘‘chronic proved the diagnosis of or the treatment outcome for deep dys-
pelvic pain.’’ Mental health professionals have rarely been in- pareunia (Howard, 2004). Another possible exception to the
volved in the assessment or diagnosis of deep dyspareunia/ lack of attention to pain symptomatology in the study of deep
chronic pelvic pain or the potential underlying pathologies ex- dyspareunia is a recent study by Leserman et al. (2006) which
cept when the patient’s reaction to the pain has been considered found that chronic pelvic pain reports could be subtyped into
‘‘excessive.’’ In such cases, diagnoses related to somatoform seven different categories. Unfortunately, this study must be
disorders are often used. considered preliminary because it was based on a retrospective
Women identifying deep dyspareunia as their major com- chart review by one gynecologist and as far as can be determined
plaint will typically visit their gynecologist who will take a his- did not separate intercourse related from non-intercourse related
tory and attempt to recreate the reported pain during a manual pain.
gynecological examination. It would not be unusual for this Despite the general acceptance of the etiologically based
examination to be followed up by a variety of tests, often includ- pathology approach, there is, in fact, ongoing and significant
ing transvaginal ultrasonography and laparoscopy. In fact, de- controversy about which pathologies are etiologically linked to
pending on the pathology suspected, there are a very large deep dyspareunic pain (Ferrero et al., 2008; Howard, 2004).
number of investigations that can be pursued (Howard, 2004). If Even for those pathologies where there appear to be strong sta-
pathology is found that appears to be linked to the pain, then tistical associations between the pathology (e.g., endometriosis)
medical or surgical treatment is often prescribed. As a result, and deep dyspareunia, there are substantial numbers of women
there has been much clinical and research attention given to the suffering from endometriosis who do not report dyspareunia of
underlying potential pathologies and relatively little attention any kind or who report chronic pelvic pain unrelated to inter-
given to describing pain characteristics (e.g., location, intensity, course. Moreover, the severity of these pathologies (e.g., endo-
quality, duration, etc.). metriosis) does not appear to predict the severity of the dyspa-
This diagnostic strategy for deep dyspareunia reflects a stan- reunia when it does exist (Porpora et al., 1999). How to interpret
dard and traditional medical approach to the diagnosis of many the nature of the association between diseases such as endo-
chronic or recurrent pain conditions. Furthermore, this approach metriosis and deep dyspareunia is further complicated by a re-
has been specifically rationalized for deep dyspareunia based on cent study suggesting that for a large percentage of women suf-
the commonly accepted idea that visceral (i.e., deep dyspareu- fering from endometriosis and deep dyspareunia, the onset of
nia) as opposed to somatic pain (i.e., superficial dyspareunia) is the dyspareunia long preceded the onset of the endometriosis
not easily localizable and that such pain is often experienced by (Ferrero et al., 2005).
the patient distant from its pathological source. If true, this local- Overall, it is impossible to evaluate whether the predom-
ization difficulty is likely to render invalid a classification based inant etiologically based pathology approach to deep dyspa-
on self-reported pain symptoms (e.g., location, intensity, qual- reunia is justified because there is almost no empirical re-
ity). In fact, it is not at all clear how deep, ‘‘deep dyspareunia’’ is. search investigating the validity of this approach or testing it
There are no guidelines, consensus or reliability studies to deter- against other approaches. There are a small but growing
mine the boundaries of vulvar, pelvic or abdominal pain though number of clinicians and researchers who are attempting to
it is clear that all can result in pain during intercourse (Butrick, merge the traditional view of deep dyspareunia/chronic
Sanford, Hou, & Mahnken, in press; Leserman, Zolnoun, Melt- pelvic pain with a symptom based pain syndrome view (Ab-
zer-Brody, Lamvu, & Steege, 2006). In fact, the DSM-IV-TR rams et al., 2006; Howard, 2003; Steege, Metzger, & Levy,
only refers to genital pain in its criteria. In the associated text, it 1998; Steege & Zolnoun, 2009) and a non-reductionist bio-
does mention deep pain but does not actually refer to where it is. psychosocial view of pain. This approach appears promising
As far as can be determined, there is almost no empirical but also lacks corroborating empirical data. One thing, how-
diagnostic literature concerning deep dyspareunia. There are ever, is clear from the existing diagnostic literature concern-
diagnostic literatures concerning all the pathological states that ing deep dyspareunia/chronic pelvic pain. No one working in
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300 Arch Sex Behav (2010) 39:292–303
this field considers this problem a sexual dysfunction. There useful to know exactly how small this group is; if it exists in
is increasing recognition and some empirical work concern- significant numbers, then this group might reasonably be clas-
ing the sexual side-effects of deep dyspareunia but these ef- sified as sexually dysfunctional. For the moment, however, there
fects are always considered secondary to the pain or the is no apparent reason to name a larger diagnostic category after
pathology (Ferrero et al., 2005; Peters et al., 2007). this apparent minority and no apparent reason to consider the en-
tire category as a sexual dysfunction.
Summary All modern definitions of pain stress its subjective nature
(Merskey & Bogduk, 1994). It therefore seems likely that self-
The most striking characteristic of the empirical diagnostic lit- report will continue to be the primary way to assess pain and dys-
erature concerning dyspareunia is its absence. This ‘‘absence’’ pareunia. Developing and standardizing self-report measures or
probably reflects a lack of scientific interest and also probably diagnostic interviews would seem to be an important and rele-
reflects the daunting task of recruiting a multidisciplinary team vant diagnostic task. Gynecological or sensory examinations
comfortable addressing basic theoretical and practical clinical sometimes confirm the existence of or help to explain the origin
issues relating to pain and sexuality. Until very recently, there of the pain, however, they cannot replace the crucial data, i.e.,
has been little overlap between clinicians and researchers work- self-reported genito-pelvic pain.
ing in the areas of sex and pain.
The most central theoretical question concerning the current
DSM-IV-TR category of dyspareunia is whether it is a unitary Recommendations
category. This seems highly unlikely. The conclusion that there
are probably several types of dyspareunia is reflected by the fact Current APA guidelines require significant empirical justifica-
that there are already two very separate literatures on superficial tion for the change of existing, or the creation of new, diagnostic
and deep dyspareunia and it seems highly likely that even within categories. It is clear that such data do not exist for dyspareunia.
these categories there are further types. For instance, the recent However, it seems equally clear that the existing diagnostic cat-
work on PVD suggests that this may be a distinct subtype of egory was created with limited empirical and theoretical justi-
superficial dyspareunia. Whether these conclusions will with- fication. As a result, major changes will be proposed.
stand serious empirical evaluation and whether symptomatic The most basic proposed change is to classify dyspareunia
differences reflect different diagnostic entities in the case of dys- with the pain disorders rather than with the sexual dysfunctions.
pareunia remains to be seen. There is no strong body of empirical evidence or theoretical
There is no empirical evidence to suggest that vaginis- reasoning to suggest that dyspareunia is a sexual dysfunction. In
mus can be reliably differentiated from superficial dyspareunia. short, the pain is not sexual; the sex is painful. As far as can be
There is accumulating evidence to suggest that there is signifi- determined, the only reason dyspareunia has been classified as a
cant overlap between these two disorders on symptom dimen- sexual dysfunction is that since DSM-III (American Psychiatric
sions relating to pain and pelvic muscle tone/control. It is not Association, 1980) almost anything having to do with the gen-
clear, however, whether there are other crucial symptom dimen- itals, sexuality or gender has been defined in this way probably
sions which would reliably differentiate superficial dyspareunia by default.
from vaginismus. Some have suggested either that superficial The major argument against this reclassification is a practical
dyspareunia and vaginismus lie on a continuum, with vaginis- one. Clinicians currently assessing and treating pain disorders
mus constituting the phobic end of the continuum, or that super- have little expertise and/or interest in dealing with genito-pelvic
ficial dyspareunia sometimes develops into vaginismus (Steege pain or dyspareunia. While some current sexual dysfunction
& Zolnoun, 2009). These hypotheses should be seriously inves- specialists have recently acquired expertise in the treatment of
tigated. In addition, there are no published diagnostic studies superficial dyspareunia, neither sexologists nor pain specialists
that have attempted to reliably differentiate deep dyspareunia are significantly involved in the treatment of deep dyspareunia.
from vaginismus. My clinical intuition is that this would be very While it might be argued that the placement of dyspareunia with
easy to do. the pain disorders may motivate professional change, it may
The major symptom of interest in dyspareunia is pain. This equally well result in this problem being ignored by everyone.
pain certainly occurs during intercourse but it almost always al- How to balance practical versus theoretical/empirical consid-
so occurs during non-intercourse situations. For some types of erations for the placement of dyspareunia in the DSM-V is not
provoked genital pain, avoiding these non-intercourse situations clear.
is not difficult, however, this should not obscure the fact that the A second basic recommended change is to collapse the two
pain is not inextricably linked to sex. While there are undoubt existing categories of dyspareunia and vaginismus into one. The
edly individuals who experience genito-pelvic pain only during original separation of these two disorders was not empirically
intercourse, these individuals appear to be a tiny minority of all based. The available data (Binik, 2009) suggest that this sepa-
the individuals experiencing genito-pelvic pain. It would be ration cannot be done reliably.
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Arch Sex Behav (2010) 39:292–303 301
A third recommendation is that the proposed new category, exception of penetration difficulties, all of the other dimen-
including dyspareunia and vaginismus, be renamed as genito- sions proposed for genito-pelvic pain/penetration disorder are
pelvic pain/penetration disorder (Table 1). This diagnosis will in principle applicable to men. Whether male dyspareunia
be based on five dimensions of diagnostic interest, including the should be included in this diagnosis or at all in the DSM-V is
following: percentage success of vaginal penetration; pain with currently not clear.
vaginal penetration; fear of vaginal penetration or of genito-
pelvic pain during vaginal penetration; pelvic floor muscle Acknowledgments The author is a member of the DSM-V Workgroup
on Sexual and Gender Identity Disorders (Chair, Kenneth J. Zucker,
dysfunction; medical co-morbidity. The pain dimension will be Ph.D.). I wish to acknowledge the valuable input I received from members
primarily based on self-reported genito-pelvic pain that occurs of my Workgroup (Lori A. Brotto, Cynthia Graham, and R. Taylor Se-
during sexual intercourse. Pain is typically defined quantita- graves) and Kenneth J. Zucker. Feedback from DSM-V Work Group
tively and therefore a dimensional pain measurement with a Advisors Sophie Bergeron, Marta Meana, and Caroline Pukall is greatly
appreciated as is feedback from Seth Davis, Melissa Farmer, Alina Kao,
specific intensity threshold requirement is required. Specific Tuuli Kukkonen, Marie Andrée Lahaie, Caroline Maykut, Laurel Pater-
information concerning pain location, frequency, quality, dura- son, and Sabina Sarin. Reprinted with permission from the Diagnostic and
tion, pattern etc. should always be assessed. For some women, Statistical Manual of Mental Disorders V Workgroup Reports (Copyright
the only situation of clinical interest will be pain during inter- 2009), American Psychiatric Association.
course. For others, this will be only one of the clinical situations
of interest (for details, see the companion review on vaginismus
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DOI 10.1007/s10508-009-9536-0
ORIGINAL PAPER
The DSM Diagnostic Criteria for Pedophilia

Ray Blanchard

Abstract This paper contains the author’s report on pedo- American Psychiatric Association’s Diagnostic and Statis-
philia, submitted on June 2, 2008, to the work group charged tical Manual of Mental Disorders (DSM). That report is
with revising the diagnoses concerning sexual and gender reproduced in the remainder of this paper, beginning in the
identity disorders for the fifth edition of the American Psy- next section. I have made no changes to the original text,
chiatric Association’s Diagnostic and Statistical Manual of except to update the references where possible.
Mental Disorders (DSM). The author reviews the previously The original report included my proposal for a revised set
published criticisms and empirical research concerning the of diagnostic criteria. In the year since I submitted my report,
diagnostic criteria for pedophilia and presents criticism and these diagnostic criteria have been extensively modified
relevant research of his own. The review shows that the DSM and—in my view—improved by input from the Paraphilias
diagnostic criteria for pedophilia have repeatedly been crit- Subworkgroup of the Sexual and Gender Identity Disorders
icized as unsatisfactory on logical or conceptual grounds, and Work Group and from official Advisors to the Paraphilias
that published empirical studies on the reliability and validity Subworkgroup. Thus, the diagnostic criteria presented later
of these criteria have produced ambiguous results. It there- in this paper are substantially different from the diagnostic
fore seems that the current (i.e., DSM-IV-TR) diagnostic cri- criteria currently being considered by the Paraphilias Sub-
teria need to be examined with an openness to major changes workgroup, and they are almost certainly different from the
in the DSM-V. criteria that will eventually be approved by the DSM-V Task
Force and the Board of Trustees of the American Psychiatric
Keywords DSM-V Hebephilia Paraphilia Pedophilia Association. I have included them because they were part of
Pedohebephilia Penile plethysmography Sexual offending my original report, and because they help to document the
evolution of the diagnostic criteria that will eventually form
part of the DSM-V.
Introduction
On June 2, 2008, I submitted a report on pedophilia to the Report on Pedophilia

work group charged with revising the diagnoses concerning
sexual and gender identity disorders for the fifth edition of the According to the DSM-IV-TR (American Psychiatric Asso-
ciation, 2000), ‘‘The paraphilic focus of Pedophilia involves
sexual activity with a prepubescent child’’ (p. 571). The DSM
R. Blanchard (&)
diagnostic criteria for pedophilia have repeatedly been crit-
Kurt Freund Laboratory, Law and Mental Health Program,
Centre for Addiction and Mental Health, 250 College Street, icized as unsatisfactory on logical or conceptual grounds, and
Toronto, ON M5T 1R8, Canada published empirical studies on the reliability and validity of
e-mail: [email protected] these criteria have been interpreted by their authors as rein-
forcing that conclusion. According to Marshall (1997), the
R. Blanchard
Department of Psychiatry, University of Toronto, diagnostic utility of the DSM diagnostic criteria is so low that
Toronto, ON, Canada these criteria are virtually ignored by clinicians as well as
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Arch Sex Behav (2010) 39:304–316 305
researchers. Marshall’s observations are presumably based the role of sexual acts was changed from signaling that pedo-
on his experience in Canadian settings, and it is possible that philia is present to signaling that it is clinically significant.
American clinicians are necessarily forced to make greater In DSM-IV, sexual acts were reinstated in Criterion A as
use of DSM diagnostic criteria for legal or administrative signs of pedophilia. Sexual acts were still mentioned in Cri-
purposes, whether they regard these criteria as useful or not. terion B, not as de facto evidence of impairment, but as one of
O’Donohue, Regev, and Hagstrom (2000), however, writing the signs and symptoms of pedophilia that might (or might
about DSM-IV (American Psychiatric Association, 1994) not) result in distress or impairment. This meaning, intended
from an American perspective, endorsed Marshall’s (1997) or not, is implied by the wording of Criterion B: ‘‘The fan-
observations regarding the practical irrelevance of DSM tasies, sexual urges, or behaviors cause clinically significant
criteria. It therefore seems that the DSM-IV-TR diagnostic distress or impairment in social, occupational, or other impor-
criteria need to be examined with an openness to major tant areas of functioning.’’
changes in the DSM-V. In DSM-IV-TR, the wording of Criterion A remained iden-
In this paper, I review the previously published criticisms and tical to that in DSM-IV. The wording of Criterion B, however,
empirical research concerning the diagnostic criteria for pedo- was changed back to resemble that of Criterion B in DSM-III-
philia, present criticism and relevant research of my own, pro- R: ‘‘The person has acted on these sexual urges, or the sexual
pose a revised set of diagnostic criteria for the consideration of urges or fantasies cause marked distress or interpersonal
the Sexual and Gender Identity Disorders Work Group, and difficulty.’’ Thus, in DSM-IV-TR, the datum, sexual acts, has
explain the rationale for the wording that I propose. I naturally been used in two different ways. In Criterion A, it is evidence
make frequent reference to the diagnostic criteria for pedophilia that the patient is pedophilic. In Criterion B, it is evidence that
in the DSM-III (American Psychiatric Association, 1980), the patient’s pedophilia is materially affecting his or her
DSM-III-R (American Psychiatric Association, 1987), DSM-IV, functioning in society. In other words, sexual acts simulta-
and DSM-IV-TR. These criteria are reproduced in the Appendix neously indicate that pedophilia is present and that it is
to this paper. causing problems.
A useful way to conceptualize the diagnostic criteria in
DSM-IV-TR is the following: There is one sufficient condition
History and Overview of the Diagnostic Criteria for diagnosing pedophilia—a history of sexual acts involving
children. That is sufficient because sexual acts satisfy the signs/
DSM-III had only one key diagnostic criterion, Criterion A, symptoms criterion and the distress/impairment criterion.
which concerned signs and symptoms of pedophilia. From There are no necessary conditions for diagnosing pedophilia.
DSM-III-R onward, there have been two key diagnostic cri- Either fantasies or urges can be used to make the diagnosis,
teria. Criterion A still concerned signs and symptoms. Cri- provided they are accompanied by marked distress or inter-
terion B concerned distress and impairment. Both criteria had personal difficulty.
to be satisfied to diagnose the disorder of pedophilia.
In DSM-III, Criterion A included acts and fantasies invol-
ving sexual interference with children. Sexual acts were Prior Logical and Conceptual Criticism
clearly conceptualized as signs of pedophilia.
In DSM-III-R, sexual acts were removed from Criterion A, Role of Sexual Acts in the Diagnostic Criteria
leaving sexual urges and fantasies about children as the des-
ignated symptoms. Sexual acts were inserted into the newly Criticism
formulated Criterion B, which states, ‘‘The person has acted
on these urges, or is markedly distressed by them.’’ The First and Frances (2008) have recommended that Criterion A
grouping of sexual acts with psychological distress in a for all paraphilias be restored to its DSM-III-R wording, that
clinical significance criterion implies that sexual acts are de is, that sexual acts or behaviors should be removed from it.
facto evidence of psychosocial impairment.1 In other words, Although First and Frances write about paraphilias in general,
their major examples are pedophilia and rape (which is not a
paraphilia per se). When they make their argument against the
1
In the DSM definition of mental disorder (e.g., DSM-IV-TR, p. xxxi), inclusion of sexual acts in Criterion A, they use the example
‘‘an important loss of freedom’’ (presumably including imprisonment) is of rape:
listed along with other sequelae that make a behavioral or psychological
syndrome clinically significant: present distress (e.g., a painful symp- The addition of ‘‘or behaviors’’ [to Criterion A in DSM-
tom), disability (i.e., impairment in one or more important areas of IV] led some forensic evaluators to conclude that sexual
functioning), and an increased risk of suffering death, pain, or disability.
offenders might qualify as having a mental disorder
Since sexual acts against children are serious criminal offenses, they are
closely associated with criminal conviction and incarceration (loss of based only on their having committed sexual offenses
freedom). (e.g., rape)…. The revised Criterion A wording has
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306 Arch Sex Behav (2010) 39:304–316
sometimes been used to justify making a paraphilia In a series of studies in my laboratory, my predecessor,
diagnosis based solely on a history of repeated acts of Kurt Freund, M.D., D.Sc., and I specifically studied men
sexual violence, which is then argued as satisfying the who had committed sexual offenses against children but
statutory mandate for the presence of a ‘‘mental abnor- who claimed that they were sexually attracted only to adults
mality’’…. Defining paraphilia based on acts alone blurs (Blanchard, Klassen, Dickey, Kuban, & Blak, 2001; Blan-
the distinction between mental disorder and ordinary chard et al., 2006; Freund & Blanchard, 1989; Freund &
criminality. (p. 1240) Watson, 1991). One example will suffice. Blanchard et al.
(2001) studied 59 men who had charges, convictions, or
Comment/Response credible accusations of illegal sexual behavior involving
three or more unrelated (male or female) children under the
First and Frances’s argument against diagnosing paraphilia age of 12, no charges (etc.) involving persons age 15 or older,
from sexual offenses seems reasonable if not compelling and no charges involving related persons of any age. These
when the clinical issue is diagnosing paraphilia—they do not patients stated in interview that they felt a greater sexual
say what paraphilia—from multiple episodes of rape. It breaks attraction to females age 17 and older than to any other class
down when the clinical issue is that of diagnosing pedophilia. of person. The self-report of the majority was directly con-
In clinical practice, the patient’s history of sexual offenses tradicted by their laboratory results. On phallometric test-
against children is often the only basis for making a diagnosis ing, 61% produced substantially greater penile tumescence
of pedophilia. It is well established that self-report alone can- to audiovisual depictions of children than to depictions of
not be used to diagnose pedophilia in offenders against chil- adults. When the same phallometric test and diagnostic cut-
dren (see, e.g., Kingston, Firestone, Moulden, & Bradford, ting score were applied to 27 sex offenders who had extensive
2007; Marshall, 1997; O’Donohue & Letourneau, 1993; histories of sexual activity with (consenting or nonconsent-
O’Donohue et al., 2000; Wormith, 1983). Men whose his- ing) females age 17 and older, only 1 (4%) was classified as
tories of sexual offending against children are so extensive pedophilic.
that they cannot plausibly be explained by anything besides Although phallometric testing can sometimes be useful,
pedophilia may nonetheless deny that they have a sexual especially when conducted in laboratories that calculate and
preference for children or else claim that they had ‘‘a prob- adjust their diagnostic cutting scores to maintain high spec-
lem’’ in the past but that their sexual feelings for children have ificity, it is not widely available. Because of the general un-
now disappeared.2 availability of phallometric testing (or alternative laboratory
The widespread clinical opinion that self-report is unre- tests) and because of the general unreliability of self-report in
liable in pedophiles has been reinforced by laboratory stud- pedophiles, repeated sexual acts involving children are prac-
ies. In these studies, sexual interest in children was measured tically indispensable as a diagnostic sign of pedophilia. The
with phallometric testing, a procedure for assessing erotic use of sexual acts as de facto evidence of psychosocial im-
interests in male adults and adolescents. In this procedure, pairment is a somewhat different matter that should be con-
the examinee’s penile blood volume is monitored while he sidered separately.
is presented with a standardized set of laboratory stimuli
depicting a variety of potentially erotic activities or objects. Paradoxical Effects of the Distress/Impairment Criterion
The examinee’s penile blood volume increases (i.e., degrees
of penile erection) are taken as an index of his relative at- Criticism
traction to the different classes of stimuli. When phallometric
testing is used to measure erotic age-preference, the labora- The attempt to separate the diagnostic criteria for pedophilia
tory stimuli include visual and auditory representations of (and other paraphilias) into signs and symptoms (Criterion A)
children and adults. vs. distress or impairment (Criterion B) has not been accom-
panied by an appropriate adjustment to terminology. This has
2
It should be noted that these offenders have little objective motivation led to the unsatisfactory result that it is necessary to be dis-
to be truthful and many good reasons to dissemble. Offenders are not tressed or impaired by a paraphilia in order to have a para-
necessarily rewarded for being truthful about pedophilic impulses; they philia. The problem has been partially patched over in DSM-
might experience even more severe consequences of their actions if they
IV-TR by substituting societal judgments about impairment
acknowledge being pedophiles. Furthermore, some common treatment
options are not really attractive, from the patient’s point of view. Many for the patient’s. Thus, a man who has an erotic preference for
clinicians have turned to ‘‘relapse-prevention’’ treatment of pedophiles, children and who engages children sexually in real life is a
which means, in essence, teaching pedophiles to control themselves. pedophile, regardless of his feelings about his situation, be-
This may well be the best option relative to further offending and in-
cause sexual acts with children count as impairment. This
carceration, but a life of sexual denial would hardly be viewed by most
people as desirable in an absolute sense. The same considerations apply solution has not, however, been adequate in the eyes of all
to treatment with sex-drive-reducing medication. critics. Green (2002) wrote of the DSM-IV-TR:
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Arch Sex Behav (2010) 39:304–316 307
So what then of the pedophile who does not act on the of diagnostic criteria into signs/symptoms and distress/impair-
fantasies or urges with a child? Where does the DSM ment than is the current DSM language.3
leave us? In Wonderland. If a person does not act on the
fantasies or urges of pedophilia, he is not a pedophile. A The Meanings of Recurrent and Intense
person not distressed over the urges or fantasies and who
just repeatedly masturbates to them has no disorder. But Criticism
a person who is not distressed over them and has sexual
contact with a child does have a mental disorder. (p. 470) O’Donohue et al. (2000) criticized various aspects of Criterion
A in DSM-IV, which reads, ‘‘Over a period of at least 6 months,
Comment/Response recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors involving sexual activity with a prepubescent child or
One solution to this diagnostic conundrum might be applied children.’’ Criterion A has the identical wording in DSM-IV-TR,
to the paraphilias in general. The DSM-V could distinguish so their comments would apply to the current DSM as well.
between paraphilias and paraphilic disorders. A patient who As an overall evaluation, O’Donohue et al. state that Cri-
satisfied the signs and symptoms criterion (Criterion A in terion A ‘‘seems too vague and thus precludes the clinician
DSM-IV-TR) would be ascertained—not diagnosed—as from assessment without making inferences…Because each
having a paraphilia. A patient who satisfied the signs/symp- clinician might draw different inferences, the reliability, and
toms criterion and the distress/impairment criterion (Crite- thereby the validity, of the criterion is reduced’’ (p. 99). They
rion B in DSM-IV-TR) would be diagnosed as having a note that there is no definition of recurrent (beyond ‘‘more
paraphilic disorder. This solution should be especially useful than once’’) or of intense. In other words, the DSM specifies
to researchers. It would prevent a paraphilia from becoming inherently quantitative indicators but does not specify the
invisible to clinical science just because it lacks any second- critical threshold quantities. A similar objection was raised
ary effect of disturbing the individual or others. by Marshall (1997), who wrote, ‘‘It would improve things if
The hypothetical patient conjured by Green (2002) rep- future diagnostic manuals were to specify what ‘recurrent’
resents a particularly challenging test of this conceptualiza- means with respect most particularly to behavior, but also for
tion. It is therefore worthwhile re-examining Green’s exam- fantasies and urges’’ (p. 154).
ple in more detail. Suppose there exists a pedophilic man
whose sexual interest is solely directed at children. His mas- Comment/Response
turbation fantasies exclusively concern children, and he feels
no self-disgust after ejaculation. He feels no dissatisfaction The language criticized by Marshall and O’Donohue et al.
with his pedophilic orientation in general and he has no wish was introduced in DSM-III-R. One way of addressing this
to be otherwise. He feels sexual ‘‘urges’’ toward children, but criticism involves returning to the model of an earlier DSM.
he has never approached a child sexually, and there is no In some ways, the approach to quantifying pedophilic
possibility that he would ever do so. He does not even par- feelings in DSM-III was more elegant than in the later edi-
ticipate in sexual offenses against children at second hand by tions. Criterion A of DSM-III reads, ‘‘The act or fantasy of
accessing child pornography. engaging in sexual activity with prepubertal children is a
According to the distinction I proposed earlier, the hypo- repeatedly preferred or exclusive method of achieving sexual
thetical patient has a paraphilia but not a paraphilic disorder. excitement.’’ If one makes the reasonable assumption that
The professional-acceptance test of the proposed terminol- ‘‘preferred’’ means ‘‘preferred over adults,’’ then the criterion
ogy is this: How many clinicians would be comfortable with can be interpreted to mean that a pedophile is someone who is
the conclusion that this man has no disorder? The answer is more attracted to children than to adults. That notion can
probably: Not many. What prevents this from posing a seri- readily be applied to self-report. Patients who are willing and
ous practical problem is that few real patients are likely to able to describe their erotic preferences at all can almost
match the profile of the hypothetical patient. Such a combi-
3
nation of behaviors and attitudes, in real life, would be very When the distinction between paraphilias and paraphilic disorders is
rare. How could one experience a lifetime of sexual ‘‘urges,’’ applied to other anomalous erotic behaviors, it will tend to correlate with
a distinction between low severity vs. high severity, or benign vs. malig-
which are never satisfied, with no sense of frustration? If the
nant. For example, a man or woman with masochistic interests in light
absence of any real-life gratification causes no distress at all, spanking or verbal abuse from a safe, consensual partner is less likely to
can one really say there was an ‘‘urge’’ in the first place? experience distress or impairment than a person with strong masochistic
In conclusion, the proposed terminology identifies Green’s interests that cause serious injury or risk of death. Since real-life exam-
ples of mild and harmless masochism, mild and harmless sadism, mild
hypothetical patient as a pedophile whereas the DSM-IV-TR
and harmless fetishism, and so on, are relatively common, the para-
does not. The distinction between paraphilias and paraphilic philia/paraphilic disorder distinction may seem more intuitive when
disorders may actually be more compatible with the separation applied to these other interests than when applied to pedophilia.
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308 Arch Sex Behav (2010) 39:304–316
certainly say whether their sexual feelings for children are as a school bus driver because it fulfills a sexual desire
greater than, less than, or approximately equal to their feel- to be around children, is that choice considered a behav-
ings for adults. The notion can just as easily be applied to ior that is sufficient to fulfill the criterion? Suppose that
phallometric testing or to any other method for laboratory the driver has not actually touched a child in an inap-
measurement of sexual response that might be devised in the propriate manner, but is clearly behaving because of his
future (e.g., fMRI).4 Even the most primitive laboratory or her sexual attraction. Does that constitute a behavior
quantifications, if they are clinically usable at all, will allow that is sufficient to meet this criterion? Another non-
the practitioner to determine whether patients’ sexual res- contact behavior, for example, might be purchasing
ponses to children are greater than, less than, or approxi- child pornography. Would that constitute a behavior
mately equal to their responses to adults. If one wants to that is sufficient to meet the criterion? Should clinicians
minimize false positive results, one can limit the ascertain- be assessing microresponses, such as staring at chil-
ment of pedophilia to those examinees who respond sub- dren, in order to assess for pedophilia? Could this con-
stantially more to children than to adults (e.g., Blanchard stitute relevant behavior for the diagnosis? Again, be-
et al., 2001). cause the criterion is unclear, it becomes difficult for
The foregoing approach could not be applied to the patient’s clinicians to reliably diagnose this disorder. (p. 100)
sexual history, that is, one could not reliably ascertain patients’
erotic age-preferences by calculating whether the number of Comment/Response
children they have engaged sexually is greater than, less than,
or equal to the number of adults. The variables of sexual expe- O’Donohue et al.’s comments are not without merit and their
riences with children and sexual experiences with adults are examples are not unrealistic. My laboratory has, in fact, re-
influenced by too many factors besides the patient’s prefer- ceived referrals from group homes for mentally retarded per-
ences: (a) Sexual interaction with consenting adults is legal in sons when a patient’s intense staring at children alerted staff to
most jurisdictions, whereas sexual interaction with children is possible pedophilia. In practice, however, behaviors such as
a criminal offense, whether the children are consenting or not. staring or arranging to be in the company of children are not
(b) Opportunities to meet adults and to be alone with adults in feasible as primary signs of pedophilia (although they might
privacy are much greater than opportunities to meet (unre- contribute to a clinician’s confidence in his or her diagnosis).
lated) children and to be alone with them. (c) Social pressures The acquisition of child pornography is another matter. Anal-
would tend to push pedophiles to experiment sexually with ysis of data from my laboratory has shown that child pornog-
adults in hopes of finding them acceptable sexual partners, raphy use may actually be a stronger indicator of pedophilia than
whereas social mores would tend to discourage anyone, pedo- is sexual offending against children (Seto, Cantor, & Blanchard,
philic or not, from experimenting sexually with children. (d) 2006; see also Blanchard et al., 2007). Another behavior that
Law and social norms would encourage pedophiles to make should be considered in the next revision of the DSM is a pa-
use of adults as ‘‘second-best’’ sexual outlets in place of chil- tient’s sexual chat and/or attempts to arrange a meeting with a
dren, but these factors (in contemporary society, anyway) dis- police officer posing as a child on the Internet.
courage the use of children as substitutes for adults.
For the foregoing reasons, some other approach must be
Duration of Signs and Symptoms
used to make inferences about erotic age-preference from
sexual history data. I discuss this matter in a later section.
Criticism
The Domain of Relevant Behaviors
O’Donohue et al. (2000) question whether the DSM-IV (and
DSM-IV-TR) Criterion A requirement that signs and symp-
Criticism
toms have persisted for 6 months is justified:
O’Donohue et al. raise a more subtle problem regarding the the characteristic of the fantasies, urges, or behaviors re-
seemingly clear term behaviors in Criterion A of DSM-IV and curring over a 6-month period is problematic. The inclu-
DSM-IV-TR: sion of a minimal temporal criterion is understandable in
order to refer to something that has some temporal sta-
Another question pertaining to the first criterion is what
bility. What is less clear is why 6 months?…. Accord-
characterizes ‘‘behavior’’? If a person chooses to work
ing to Dohrenwend and Dohrenwend (1965), temporal
4
stability of symptoms is essential because valid diagnoses
In a study conducted after this report was submitted, Blanchard et al.
must rule out the possibility of transient stressors (such as
(in press) demonstrated that the notion of preference not only can, but
probably must, be applied in the interpretation of phallometric test combative conditions) mimicking the symptoms of a dis-
results. order (PTSD). This is not a concern regarding pedophilia.
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Arch Sex Behav (2010) 39:304–316 309
There are no transient stressors that can account for this We must ask what the best alternative might be to in-
disorder in the short-term. (p. 101) crease the specificity of the DSM diagnostic criteria.
One possibility is specifying a number of occurrences
Comment/Response during a time period and using it as a cutoff. (p. 101)
I agree with this criticism, including the last sentence. There is

Comment/Response
evidence that the probability of pedophilia increases with the
number of victims (see below), but I do not know of evidence
O’Donohue et al.’s use of the phrase, ‘‘during a time period,’’
that the probably of pedophilia relates to the time interval be-
is puzzling, given their previous criticism of the 6-month
tween victims. It is possible that certain acute situations (e.g.,
requirement. Other than that, their suggestion that a numeric
manic episodes, drug or alcohol binges) might cause a person to
cutoff be applied to number of sexual acts (or number of sex-
approach several children within the space of a few days, or to
ual victims) in ascertaining pedophilia accords with empiri-
approach two or more children (e.g., siblings or playmates) in a
cal data.
single episode. Generally speaking, however, these excep-
As previously stated, Blanchard et al. (2001) found that 61%
tional situations are easy to identify.
of men with sexual offenses against three or more children
produced substantially greater penile tumescence to audiovisual
Number of Sexual Acts Involving Children
depictions of children than to depictions of adults. This test
result was found for 42% of men with offenses against two
Criticism
children and 30% of men with offenses against one child. Thus,
there clearly is a correlation between the number of sexual of-
It is now widely accepted that not all child molesters are
fenses against children and the presence of pedophilia, even
pedophiles, and not all pedophiles are child molesters (e.g.,
among men who deny any sexual interest in children.
Konopasky & Konopasky, 2000; Seto, 2002). The existence
For reasons already explained, pedophilia cannot be ascer-
of pedophiles who never approach a child sexually poses a
tained from patients’ numbers of sexual encounters with chil-
problem for the distress/impairment criterion. The existence
dren relative to their numbers of encounters with adults. It is
of persons who have engaged children sexually but do not
necessary to consider the absolute number of sexual encounters
prefer children poses a problem for the signs/symptoms cri-
with children. The results of Blanchard et al. (2001) show that
terion. The solution to the signs/symptoms criterion involves
absolute cutoff scores matter, at least up to three known of-
the answer to this: How does one use information about
fenses. The problem of having to choose the best cutoff value
sexual acts with children to decide which child molesters are
may therefore be unavoidable.
probably pedophiles and which are not?
O’Donohue et al. touch upon the problem of deciding
which child molesters are pedophiles in a few places. In their
Quantitative Threshold for Sexual Acts
first mention of this matter, they observe the following:
In the DSM-III-R, only urges and fantasies were relevant Criticism
for satisfying the first criterion. In the DSM-IV these or
behaviors can satisfy this criterion. This could be O’Donohue et al. (2000) make a rather radical suggestion
viewed as a positive change as it allows the clinician to about the number of sexual acts with children needed to diag-
rely on overt phenomena to make this diagnosis. How- nose a disorder:
ever, it could also be problematic. The basic question is
As an alternative to viewing pedophilia as a trait, it can be
whether there are two kinds of cases that should remain
viewed as a behavioral disorder. As such, a single behavior
distinguished. The first kind of case is represented by an
of a sexual nature would be sufficient to categorize some-
inclination, propensity, or motivation—an underlying
one as having pedophilia response disorder. The extent to
diathesis. The second kind of case is represented by the
which the behavior(s) persist would be subsumed under the
presence of disordered behavior, which may or may not
subcategory of a single occurrence that is acute in its
be related to the diathesis. (pp. 100–101)
course, or under a more chronic condition. A single in-
I understand this to mean that the personological character- stanceofsexual behaviorwith achild should be sufficient to
istic underlying a specific act of child molestation could be label someone as having a disorder. We argue that a single
either pedophilia or something different, such as antisociality incidence would be sufficient on three grounds: (a) from
plus opportunity. In a later passage they seem to suggest, epidemiological data, one incidence places the adult in an
although not in these words, that the qualitative distinction infrequent subgrouping; (b) it is the only nonarbitrary
might be made on quantitative grounds: demarcation—none clearly would be inappropriate; and
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310 Arch Sex Behav (2010) 39:304–316
(c) one incident can cause significant harm to a child and an In addition, why does a person need to be distressed by the
adult. (p. 103, emphasis in original) fact that he or she is attracted to children in order for the
diagnosis of pedophilia to be made? By the mere fact that
Comment/Response an attraction exists, the diagnosis of pedophilia is war-
ranted…. We recommend that Criterion B be removed
I have two points to make in response to this. The first is that from the DSM diagnostic criteria of pedophilia. (p. 102)
O’Donohue et al.’s proposal to reconceptualize pedophilia as
Marshall (1997) is in essential agreement with O’Don-
a behavioral disorder and rename it pedophilia response
ohue et al. about the superfluity of the clinical significance
disorder has nothing to do with my proposal to distinguish
criterion: ‘‘That pedophilia should be diagnosed only if it
between paraphilias and paraphilic disorders. I regard para-
causes significant distress or impairment of functioning
philias, including pedophilia, as erotic preferences or orien-
seems an odd caveat to add to the diagnostic criteria’’ (p. 154).
tations that inhere in the individual and that have some
existence independent of specific, observable actions.
The second is simply that a large proportion of persons Comment/Response
who have offended sexually against a child are not pedo-
philes. Their erotic preference is for physically mature adults, Both Green (2002) and O’Donohue et al. call special atten-
and their sexual behavior with children is caused by some tion to the ‘‘contented pedophile’’ (O’Donohue et al., 2000, p.
other motivational state or circumstance. Labeling them as 104), although Green would solve the problem by taking
persons with ‘‘pedophilia response disorder’’ is merely restat- pedophilia out of the DSM, whereas O’Donohue et al. would
ing that they have offended against a child. solve the problem by taking Criterion B out of the DSM. The
I have to agree with O’Donohue et al. that ‘‘1’’ is a unique classification of ego-syntonic, euthymic, chaste pedophiles
number and that one sexual offense against a child places a may be viewed as a psychiatric example of the generalization
person in a statistically infrequent (and suspicious) category. that ‘‘hard cases make bad law.’’ As I have already indicated,
I do not, however, think it follows from that that ‘‘1’’ is the I doubt that such cases are common, compared with the
optimum cutoff for ascertaining pedophilia. numbers who are distressed by their pedophilia or else are
comfortable enough with it and are prepared to interact with a
Clinical Significance, Distress, and Impairment child when the opportunity presents. As I also indicated, I
think that ascertaining such hypothetical cases as pedophilic
Criticism without diagnosing them as having a pedophilic disorder
would be a reasonable compromise.
O’Donohue et al. have two different criticisms about the I have no suggestions for quantifying ‘‘marked distress’’ or
references to ‘‘distress’’ and ‘‘impairment’’ in DSM-IV, which ‘‘interpersonal difficulty’’ or for determining the threshold
would also apply to the references to ‘‘distress’’ and ‘‘inter- values that would trigger the application of the distress/
personal difficulty’’ in DSM-IV-TR. The first criticism is that impairment criterion. If ‘‘interpersonal difficulty’’ simply
the clinical significance criterion is badly worded; the second means that patients are sexually attracted to children rather
criticism is that it is not needed at all. The first criticism is than to adults, then it is redundant with their ascertainment as
relatively minor: ‘‘It is unclear about what constitutes ‘clini- pedophiles, as O’Donohue et al. sensibly point out.
cally significant’ distress. Does clinically significant stress
need to result in a stress-related Axis I diagnosis—or is the Definition of Pedophilia and Age of Erotic Objects
standard weaker?’’ (pp. 101–102). Their second criticism
goes to the heart of the distress/impairment criterion for pedo- Criticism
philia.
Moreover, what constitutes impairment in social func- The DSM-IV-TR follows the traditional definition of pedo-
tioning? A person should be considered impaired by the philia as sexual interest in, or sexual activity with, prepub-
mere fact of having sexual fantasies, urges, or behaviors escent children. This definition, if taken literally, would ex-
targeting children instead of people their own age. Gi- clude from diagnosis a sizable proportion of patients whose
ven that Criterion A is met, it could be construed that strongest sexual feelings are for physically immature persons.
Criterion B is always met. It does not seem possible for a The existence of patients whose erotic interest centers on
person sexually interested in children not to be socially pubescent rather than prepubescent children has been recog-
impaired in some way because societal norms dictate nized for decades. Glueck (1955) coined the term hebephiles
that it is abnormal for a person to be sexually interested to refer to them. Despite the familiarity of this phenomenon
in children. to experienced clinicians, few have criticized the DSM for
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Arch Sex Behav (2010) 39:304–316 311
ignoring it. One notable exception is Marshall (1997), who measures. The results have shown hebephiles to be inter-
wrote of the DSM-IV: mediate between pedophiles and teleiophiles with regard to
IQ (Blanchard et al., 2007; Cantor et al., 2004), completed
The age specified for the child identified as the object of
education (Blanchard et al., 2007), school grade failure and
the pedophile’s fantasies, urges, or behavior also pre-
special education placement (Cantor et al., 2006), head inju-
sents problems. Whereas there must be some cutoff
ries before age 13 (Blanchard et al., 2003), left-handedness
age, defining pedophilia as an attraction to or involve-
(Blanchard et al., 2007; Cantor et al., 2005), and stature
ment with prepubescent children, and defining pubes-
(Cantor et al., 2007).
cence as typically age 13 years, seems arbitrary….
The main goal of Blanchard et al. (2009) was to validate
Also, a significant number of offenders molest victims
the concept of hebephilia by examining the agreement be-
who are postpubescent but still quite young. Does this
tween self-reported sexual interests and objectively recorded
mean that these offenders do not have a mental disorder
penile responses in the laboratory. The participants were 881
when those who molest younger children do? (p. 154)
men who were referred for clinical assessment because of
paraphilic, criminal, or otherwise problematic sexual behav-
Comment/Response ior. Within-group comparisons showed that men who ver-
bally reported maximum sexual attraction to pubescent chil-
Marshall’s criticism is reinforced by the findings of a recent dren had greater penile responses to depictions of pubes-
study from my laboratory (Blanchard et al., 2009; see also cent children than to depictions of younger or older persons.
Blanchard, 2009). We began this study by reviewing devel- Between-groups comparisons showed that penile responding
opmental research from the field of pediatric endocrinology, distinguished such men from those who reported maximum
which showed that (contemporary) pubescent children are attraction to prepubescent children and from those who re-
generally those from age 11 or 12 years to about 14 or 15; ported maximum attraction to fully grown persons. These
prepubescent children are those who are younger. We then results indicated that hebephilia exists as a discriminable
reviewed data on the typical ages of victims of child sexual erotic age-preference.
abuse, which yielded the following information. The implication of the foregoing study is that the DSM-V
The modal age of victims of sexual offenses in the United should recognize the clinical and scientific importance of
States is 14 years (Snyder, 2000, Fig. 1; Vuocolo, 1969, p. 77); patients preferentially attracted to children who have entered
therefore, the modal age of victims falls within the time-frame of puberty but are still physically quite immature. This would
puberty. In anonymous surveys of social organizations of per- systematize what is already happening unsystematically.
sons who acknowledge having an erotic interest in children, Levenson (2004, p. 360) has noted that practitioners evalu-
attraction to children of pubescent ages is more frequently re- ating patients for civil commitment under sexually violent
ported than is attraction to those of prepubescent ages (e.g., predator statutes typically diagnose such patients with ‘‘Para-
Bernard, 1975; Wilson & Cox, 1983). In samples of sexual philia NOS (Hebephilia).’’
offenders recruited from clinics and correctional facilities, men
whose offense histories or assessment results suggest erotic
interest in pubescents sometimes outnumber those whose data Studies of Reliability and Validity
suggest erotic interest in prepubescent children (e.g., Cantor
et al., 2004; Gebhard, Gagnon, Pomeroy, & Christenson, 1965; Research by Kingston et al. (2007)
Studer, Aylwin, Clelland, Reddon, & Frenzel, 2002). The fore-
going findings are consistent with the results of large-scale sur- Findings
veys that sampled individuals from the general population and
included questions regarding sexual experiences with older Kingston et al. (2007) studied adult men who had been con-
persons when the respondent was underage. These results sug- victed of hands-on sexual offences against an unrelated male
gest that a substantial proportion of respondents who had had or female child who was under the age of 16 at the time of the
such experiences reported ages at occurrence that fall within the offence. The patients were assessed at a university teaching
normal time-frame of puberty (Boney-McCoy & Finkelhor, hospital in Ottawa, Ontario between 1982 and 1992. If police
1995; Briere & Elliott, 2003; Finkelhor, Ormrod, Turner, & records indicated that a patient had ever offended against an
Hamby, 2005). The available data therefore indicate that
hebephilia may be as great a clinical problem as pedophilia.
Blanchard et al. (2009) also reviewed studies demon-
strating the utility of specifying a hebephilic group for re- 5
The term teleiophilia (Blanchard et al., 2000) denotes the erotic pref-
search purposes. These studies have compared pedophilic, erence for persons between the ages of physical maturity and physical
hebephilic, and teleiophilic5 men on a variety of dependent decline.
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312 Arch Sex Behav (2010) 39:304–316
adult or against a family member, he was excluded from the kind of effect size analysis here, because there was no com-
analysis. The patients were diagnosed by psychiatrists as parison group of men who lacked a history of offenses against
pedophilic or not pedophilic according to DSM-III or DSM- children. The application of these findings to the DSM-IV-TR
III-R criteria (hereafter, DSM pedophiles and DSM nonpe- diagnostic criteria is imprecise in any event, since the psy-
dophiles, respectively). The psychiatrists had access to pre- chiatric diagnoses were made according to DSM-III or DSM-
vious medical charts and police reports, including diagnostic III-R criteria.
history, previous psychological assessment, psychosocial
history, and criminal history. Research by Levenson (2004)
After their clinical psychiatric diagnosis, the patients were
tested in the hospital’s phallometric laboratory. Phallometric Findings
test results were obtained for 82 DSM pedophiles and 75 DSM
nonpedophiles. The patient’s penile responses were used to Levenson (2004) studied 277 male, adult, competent, con-
compute a Pedophile Index, which was the highest response victed sex offenders in Florida prisons who received a face-
to a child divided by the highest response to an adult. Thus, to-face evaluation by psychologists or psychiatrists for sex-
scores greater than 1.0 would indicate a pedophilic prefer- ually violent predator civil commitment between July 1, 2000
ence. The authors also computed a Pedophile Assault Index, and June 30, 2001. Consistent with statutory language, these
which was the highest response to depictions of violent or subjects were examined by more than one forensic evaluator.
coercive interactions with children divided by the highest DSM diagnoses were made according to DSM-IV-TR cri-
response to depictions of cooperative or enthusiastic chil- teria. The diagnoses were coded dichotomously (yes/no) and
dren. It appears that depictions of sexual interaction with included the diagnoses most commonly considered: Pedo-
adults were not used in computing the Pedophile Assault philia, Sexual Sadism, Exhibitionism, Paraphilia NOS, Anti-
Index. social Personality Disorder, Personality Disorder NOS, Other
The mean scores of both groups on the Pedophile Index Personality Disorder, Substance Disorder, and Other Major
were greater than 1.0, which is not very surprising, given that Mental Illness.
both groups had histories of sexual offenses against children. The kappa reliability coefficient for pedophilia was .65.
Nevertheless, the DSM pedophiles had significantly higher Levenson considered this value to be merely ‘‘fair,’’ consi-
scores (more arousal to children) than the DSM nonpedo- dering the serious consequence of civil commitment fol-
philes. In contrast, the mean scores of both groups on the lowing incarceration. The kappa reliability coefficients for
Pedophile Assault Index were less than 1.0 (i.e., sadistic sadism, exhibitionism, and paraphilia NOS were even lower,
behavior toward children was less arousing than nonsadistic ranging from .30 to .47. Levenson noted that it would have
behavior), and the means of the two groups were virtually been useful to analyze the DSM-IV criteria for each diagnosis
identical. to determine if particular criteria were more or less reliable
In an additional manipulation, Kingston et al. computed a than others, but these data were not available to her.
Phallometric Deviance Index, by combining the Pedophile
Index and the Pedophile Assault Index. It is unclear what the
interpretation of this measure is supposed to be, since one com- Comment/Response
ponent of it concerns arousal to children vs. adults, whereas the
other component of it concerns arousal to coerced/mistreated Levenson’s finding for the reliability of the DSM diagnosis of
children vs. cooperative children. It is also unclear why the pedophilia is not as bad as one might have feared, given the
authors would choose to combine measures that had already very negative assessment by Marshall (1997). Furthermore,
been shown to behave differently. Using this derived variable, Packard and Levenson (2006) reanalyzed Levenson’s (2004)
they obtained the unsurprising result that ‘‘There was no sig- data using alternative measures of inter-rater reliability and
nificant relationship between individuals diagnosed as pedo- concluded that the reliabilities of DSM paraphilia diagnoses
philic according to the DSM criteria and individuals classified (including pedophilia) are generally better than indicated by
as pedophilic according to [the Phallometric Deviance Index]’’ a sole reliance on the kappa statistic.
(p. 431). Packard and Levenson found that the prevalence-adjusted
bias-adjusted kappa (PABAK; Byrt, Bishop, & Carlin, 1993)
for the diagnosis of pedophilia was .70, and they pointed out
Comment/Response that this value would be considered a ‘‘substantial’’ level of
inter-rater agreement by some statisticians (Landis & Koch,
The significant result obtained with the Pedophile Index sup- 1977). Other statistics of present interest were various pro-
ports the validity of DSM-based psychiatric diagnosis in a portions of agreement. Among all cases, the evaluators
general sort of way. It would be misleading to attempt any agreed on the presence or absence of pedophilia 85% of the
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Arch Sex Behav (2010) 39:304–316 313
time. Among cases who received at least one negative diag- Table 1 Proposed diagnostic criteria for Pedohebephilic Disorder
nosis, the evaluators agreed on a negative diagnosis 80% of A. The person is equally or more attracted sexually to children under the
the time (proportion of negative agreement). Among cases age of 15 than to physically mature adults, as indicated by self-report,
who received at least one positive diagnosis, the evaluators laboratory testing, or behavior.
agreed on a positive diagnosis 62% of the time (proportion of B. The person is distressed or impaired by these attractions, or the person
positive agreement).6 In summary, the reliability of the DSM- has sought sexual stimulation from children under 15 on three or more
separate occasions.
IV-TR diagnostic criteria for pedophilia, as re-assessed by
C. The person is at least age 16 years and at least 5 years older than the
Packard and Levenson, could be seen as acceptable.
child or children in Criterion A.
On the other hand, the diagnostic assessments may not
Specify if:
have been truly independent in all cases, because the second
Sexually Attracted to Children Younger than 11 (Pedophilic Type)
evaluator might have been aware of the opinions of the first
Sexually Attracted to Children Age 11–14 (Hebephilic Type)
(Packard & Levenson, 2006). This could have had the effect
Sexually Attracted to Both (Pedohebephilic Type)
of inflating the agreement between raters. On balance,
Specify if:
therefore, one may conservatively conclude that Levenson’s
Sexually Attracted to Males
(2004) data indicate that there is still room for improvement
Sexually Attracted to Females
in the reliability of the DSM diagnosis of pedophilia.
Sexually Attracted to Both
Proposed Diagnostic Criteria for DSM-V Commentary on the Proposed Criteria
General Considerations Number of Sexual Acts
In proposing a revised set of diagnostic criteria for DSM-V, I The most difficult challenge in improving the objectivity (and
have attempted to combine the best features from previous potential reliability) of the diagnostic criteria is choosing a
versions of the DSM with new features suggested by the minimum value for the number of separate sexual episodes
criticism and research reviewed above. The proposed criteria involving children for Criterion B. This is, in practice, a
incorporate the formal structure of DSM-III-R and the con- problem for sexual offenders with one or few known child
cept of preference from DSM-III. The proposed criteria also victims, who deny any erotic interest in children, and who
enlarge the boundaries of diagnosis to include hebephilia, have undergone no laboratory testing to assess their erotic
while preserving ‘‘classic’’ pedophilia as a specifiable sub- age-preference. These are the persons for whom the sexual
type. As in DSM-IV-TR, repeated sexual acts involving chil- behaviors clause of Criterion B completely determines the
dren indicate both that pedophilia is present and that it rep- diagnosis.
resents a disorder. Thus, the arrangement of diagnostic ele- There can be no perfect cutoff point. A higher threshold
ments into Criterion A and Criterion B does not constitute a value necessarily increases the number of false negative diag-
complete separation of signs and symptoms from distress and noses; a lower threshold value necessarily increases the num-
impairment. ber of false positive diagnoses. This trade-off is inherent.
The addition of the word ‘‘Disorder’’ to the condition is There are two further problems complicating the problem: (a)
meant as a reminder that people who meet Criterion A but not There is no ‘‘gold standard’’ to use in any statistical study of
Criterion B can still be designated as pedophiles, for purposes cutoff scores for nonadmitting patients, and (b) even if there
like research. It is unclear what, if anything, would be lost by were a gold standard, a purely statistical solution to estab-
excluding such persons from the diagnosis of mental disor- lishing the cutoff score would ignore the relative harm to the
der, since, by definition, these hypothetical individuals would patient of a false positive diagnosis and the potential harm to
not wish to change, would not distress themselves, and would society of a false negative diagnosis.
not harm anyone else. The proposed criteria are given in I have suggested a threshold value of three victims. I be-
Table 1. lieve, on the basis of my laboratory’s experience, that this
cutoff would bias the diagnostic criteria toward making false
negative diagnoses rather than false positive diagnoses. In
other words, it will tend to err on the side of underdiagnosing
6
Packard and Levenson interpreted the difference in magnitude be- pedohebephilia.
tween the proportions of negative and positive agreement to suggest that A clinician assessing an individual patient can always
‘‘the evaluators were applying stringent criteria for inclusion in a
recommend to the courts or to children’s protective agencies
diagnosis, with a preference given for eliminating false positives in
favor of potentially allowing a greater proportion of false negatives’’ that the patient be prohibited from unsupervised access to
(p. 9). children, on the grounds that the patient has already dem-
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314 Arch Sex Behav (2010) 39:304–316
onstrated a propensity to behave inappropriately with chil- Acknowledgments The author is a member of the DSM-V Work-
dren and therefore represents a risk for further offending. In group on Sexual and Gender Identity Disorders. He wishes to thank
James M. Cantor and Kenneth J. Zucker for their input regarding the
other words, the psychiatric diagnosis of pedohebephilia distinction between paraphilias and paraphilic disorders. Reprinted with
would not always be needed for the protection of society. On permission from the Diagnostic and Statistical Manual of Mental Dis-
the other hand, a false positive diagnosis of pedohebephilia orders V Workgroup Reports (Copyright 2009), American Psychiatric
could do irreparable harm to the patient. Association.
Real Children, Virtual Children, and False Children

Appendix
A substantial and still increasing number of patients are re-
ferred for clinical assessment of erotic age-preference be- Diagnostic Criteria for Pedophilia in DSM-III (1980)
cause of Internet-related offenses: Downloading child porno- A. The act or fantasy of engaging in sexual activity with
graphy, and conducting sexual chat with police officers prepubertal children is a repeatedly preferred or exclu-
posing as children or arranging rendezvous with police offi- sive method of achieving sexual excitement.
cers posing as children. I recommend that, for diagnostic B. If the individual is an adult, the prepubertal children are
purposes, photographed children and impersonated children at least 10 years younger than the individual. If the
be treated the same as real children. The validity of child individual is a late adolescent, no precise age difference
pornography use as an indictor of pedohebephilia has already is required, and clinical judgment must take into account
been demonstrated (Seto et al., 2006; see also Blanchard the age difference as well as the sexual maturity of the
et al., 2007). The erotic orientation of an adult patient who child.
chooses to flirt on the Internet with a real 12-year-old is
probably the same as that of a patient who flirts with a police
officer impersonating a 12-year-old (although this has not
Diagnostic Criteria for Pedophilia in DSM-III-R (1987)
been empirically demonstrated, to my knowledge).
A. Over a period of at least 6 months, recurrent intense
Laboratory Tests for Pedohebephilia sexual urges and sexually arousing fantasies involving
sexual activity with a prepubescent child or children
The reference to ‘‘laboratory testing’’ in Criterion A is not (generally age 13 or younger).
meant to refer solely to existing diagnostic tests (e.g., phal- B. The person has acted on these urges, or is markedly dis-
lometric testing). It is also meant to include any diagnostic tressed by them.
tests for pedohebephilia that might be developed in the future. C. The person is at least 16 years old and at least 5 years
It is well within the range of possibility that clinical diag- older than the child or children in A.
nostic fMRI tests for pedohebephilia will be developed with-
Note: Do not include a late adolescent involved in an ongoing
in the next several years. These could use experimental de-
sexual relationship with a 12- or 13-year-old.
signs and stimuli similar to those currently used for phallo-
Specify: same sex, opposite sex, or same and opposite
metric tests. The subject would be shown a standardized set of
sex.
nude images of male and female children and adults. Instead
Specify if limited to incest.
of evaluating the patient’s penile responses, the clinician
Specify: exclusive type (attracted only to children), or
would evaluate the patient’s brain responses to male and
nonexclusive type.
female children and adults. (The brain regions that activate
during sexual arousal have already been established by fMRI
studies.) Studies using fMRI technology have already dem-
Diagnostic Criteria for Pedophilia in DSM-IV (1994)
onstrated that homosexual and heterosexual teleiophiles can
be accurately differentiated according to brain activity during A. Over a period of at least 6 months, recurrent, intense
exposure to erotic photographs of adult men and women (e.g., sexually arousing fantasies, sexual urges, or behaviors
Safron et al., 2007). It has not yet been investigated whether involving sexual activity with a prepubescent child or
fMRI can differentiate accurately between pedohebephiles children (generally age 13 years or younger).
and teleiophiles. However, a few fMRI studies of pedophiles B. The fantasies, sexual urges, or behaviors cause clinically
have already been published (Schiffer et al., 2008a, 2008b; significant distress or impairment in social, occupational,
Walter et al., 2007), and it is virtually certain that a diagnostic or other important areas of functioning.
test for nonadmitting child molesters will be attempted in the C. The person is at least age 16 years and at least 5 years
near future. older than the child or children in Criterion A.
123
Arch Sex Behav (2010) 39:304–316 315
Note: Do not include an individual in late adolescence in- American Psychiatric Association. (2000). Diagnostic and statistical
volved in an ongoing sexual relationship with a 12- or 13- manual of mental disorders (4th ed., text revision). Washington,
DC: Author.
year-old. Bernard, F. (1975). An enquiry among a group of pedophiles. Journal of
Specify if: Sex Research, 11, 242–255.
Blanchard, R. (2009). Reply to letters regarding Pedophilia, Hebephilia,
Sexually Attracted to Males and the DSM-V [Letter to the Editor]. Archives of Sexual Behav-
Sexually Attracted to Females ior, 38, 331–334.
Sexually Attracted to Both Blanchard, R., Barbaree, H. E., Bogaert, A. F., Dickey, R., Klassen, P.,
Kuban, M. E., et al. (2000). Fraternal birth order and sexual
Specify if: orientation in pedophiles. Archives of Sexual Behavior, 29, 463–478.
Blanchard, R., Klassen, P., Dickey, R., Kuban, M. E., & Blak, T. (2001).
Limited to Incest Sensitivity and specificity of the phallometric test for pedophilia in
nonadmitting sex offenders. Psychological Assessment, 13, 118–
Specify type: 126.
Blanchard, R., Kolla, N. J., Cantor, J. M., Klassen, P. E., Dickey, R.,
Exclusive Type (attracted only to children) Kuban, M. E., et al. (2007). IQ, handedness, and pedophilia in adult
Nonexclusive Type male patients stratified by referral source. Sexual Abuse: A Journal
of Research and Treatment, 19, 285–309.
Blanchard, R., Kuban, M. E., Blak, T., Cantor, J. M., Klassen, P., &
Diagnostic Criteria for Pedophilia in DSM-IV-TR (2000) Dickey, R. (2006). Phallometric comparison of pedophilic interest
in nonadmitting sexual offenders against stepdaughters, biological
A. Over a period of at least 6 months, recurrent, intense daughters, other biologically related girls, and unrelated girls. Sex-
sexually arousing fantasies, sexual urges, or behaviors ual Abuse: A Journal of Research and Treatment, 18, 1–14.
Blanchard, R., Kuban, M. E., Blak, T., Cantor, J. M., Klassen, P. E.,
involving sexual activity with a prepubescent child or
& Dickey, R. (in press). Absolute vs. relative ascertainment of
children (generally age 13 years or younger). pedophilia in men. Sexual Abuse: A Journal of Research and Treat-
B. The person has acted on these sexual urges, or the sexual ment.
urges or fantasies cause marked distress or interpersonal Blanchard, R., Kuban, M. E., Klassen, P., Dickey, R., Christensen, B. K.,
Cantor, J. M., et al. (2003). Self-reported head injuries before and
difficulty.
after age 13 in pedophilic and nonpedophilic men referred for
C. The person is at least age 16 years and at least 5 years clinical assessment. Archives of Sexual Behavior, 32, 573–581.
older than the child or children in Criterion A. Blanchard, R., Lykins, A. D., Wherrett, D., Kuban, M. E., Cantor, J. M.,
Blak, T., et al. (2009). Pedophilia, hebephilia, and the DSM-V.
Note: Do not include an individual in late adolescence in- Archives of Sexual Behavior, 38, 335–350.
volved in an ongoing sexual relationship with a 12- or 13- Boney-McCoy, S., & Finkelhor, D. (1995). Prior victimization: A risk
year-old. factor for child sexual abuse and for PTSD-related symptomat-
ology among sexually abused youth. Child Abuse & Neglect, 19,
Specify if: 1401–1421.
Briere, J., & Elliott, D. M. (2003). Prevalence and psychological
Sexually Attracted to Males
sequelae of self-reported childhood physical and sexual abuse in a
Sexually Attracted to Females general population sample of men and women. Child Abuse &
Sexually Attracted to Both Neglect, 27, 1205–1222.
Byrt, T., Bishop, J., & Carlin, J. B. (1993). Bias, prevalence and kappa.
Specify if: Journal of Clinical Epidemiology, 46, 423–429.
Cantor, J. M., Blanchard, R., Christensen, B. K., Dickey, R., Klassen, P.
Limited to Incest E., Beckstead, A. L., et al. (2004). Intelligence, memory, and
handedness in pedophilia. Neuropsychology, 18, 3–14.
Specify type: Cantor, J. M., Klassen, P. E., Dickey, R., Christensen, B. K., Kuban, M.
E., Blak, T., et al. (2005). Handedness in pedophilia and hebephilia.
Exclusive Type (attracted only to children)
Archives of Sexual Behavior, 34, 447–459.
Nonexclusive Type Cantor, J. M., Kuban, M. E., Blak, T., Klassen, P. E., Dickey, R., &
Blanchard, R. (2006). Grade failure and special education place-
ment in sexual offenders’ educational histories. Archives of Sexual
Behavior, 35, 743–751.
Cantor, J. M., Kuban, M. E., Blak, T., Klassen, P. E., Dickey, R., &
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the modification of denial in child sexual abusers: Outcome and Canadian Journal of Criminology, 25, 379–390.
follow up. Child Abuse and Neglect, 17, 299–304.
O’Donohue, W., Regev, L. G., & Hagstrom, A. (2000). Problems with
the DSM-IV diagnosis of pedophilia. Sexual Abuse: A Journal of
Research and Treatment, 12, 95–105.
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DOI 10.1007/s10508-009-9577-4
ORIGINAL PAPER
The DSM Diagnostic Criteria for Exhibitionism, Voyeurism,

and Frotteurism
Niklas Långström
Published online: 19 November 2009

Abstract I reviewed the empirical literature for 1980–2008 of central textbooks in the field. Publications with relevant
on exhibitionism, voyeurism, and frotteurism for the Ameri- abstracts were studied in full text. Finally, I carefully read
can Psychiatric Association’s Sexual and Gender Identity Dis- prior versions of the DSM diagnostic criteria for these pa-
orders Work Group in preparation for the fifth edition of the raphilias from the DSM-III to DSM-IV-TR.
Diagnostic and Statistical Manual of Mental Disorders (DSM-V).
Very limited empirical support was found for major changes Results from Literature Search
of the current DSM-IV-TR criteria sets for these paraphilias.
Some of the criticism of current criteria and the balancing of Most writers ascribe the introduction of the term exhibition-
false negatives and false positive diagnoses are examined. The ism to the French 19th century physician Lasègue (e.g., Murphy
report concludes with suggestions for possible diagnostic cri- & Page, 2008). More widespread acknowledgement, however,
teria changes for the DSM-V. came with the classic Psychopathia Sexualis by German psy-
chiatrist Richard von Krafft-Ebing (1965). Following voyeur-
Keywords DSM-V Paraphilias Exhibitionism istic behavior, exhibitionistic acts are among the most common
Voyeurism Frotteurism of potentially law-breaking sexual behaviors, judging from
clinical (Abel, Becker, Cunningham-Rather, Mittelman, &
Rouleau, 1988) and general population samples (Långström &
Exhibitionism Seto, 2006). Despite this, research is limited, perhaps reflect-
ing a long-standing perception that exhibitionistic behaviors
Method are merely a nuisance compared to other sexual offences (e.g.,
Morin & Levenson, 2008; Murphy & Page, 2008). However,
In December 2008, I conducted computerized searches for the considerable overlap with other paraphilias in clinical sam-
exhibitionism, voyeurism, and frotteurism in literature dat- ples, particularly voyeurism and sadomasochism (e.g., Abel
abases Ovid MEDLINE, PsycINFO, CINAHL (nursing and et al., 1988; Bradford, Boulet, & Pawlak, 1992; Fedora et al.,
allied health literature), Books@Ovid, and PsycBooks (schol- 1992; Freund, Seto, & Kuban, 1997; Gebhard, Gagnon, Pome-
arly books published by the American Psychological Associ- roy, & Christenson, 1965), seems to occur not only because of
ation) for relevant publications published 1980–2008. The search selection biases underlying referral to clinical and forensic
strategy included the terms‘‘exhibitionism,’’‘‘voyeurism,’’or settings. In fact, Långström and Seto (2006) found similar
‘‘frotteurism,’’ respectively, anywhere in title, abstract or overlaps in their population survey of 18- to 60-year-old adults
keywords and English-only literature. I also surveyed the in Sweden of both genders.
reference lists of publications identified this way and those Interestingly, Marshall and Fernandez (2003) reviewed 10
studies using penile plethysmography with exhibitionists.
Nine of 10 suggested that exhibitionists in clinical settings did
N. Långström (&)
not have a preference for exposing themselves. Despite this
Centre for Violence Prevention, Karolinska Institutet,
POB 23000, 104 35 Stockholm, Sweden counterintuitive finding, perhaps due to heterogeneity across
e-mail: [email protected] studies and failure to ascertain exhibitionistic sexual arousal
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318 Arch Sex Behav (2010) 39:317–324
for technical and statistical power reasons, there are data sexual intercourse. However, despite being theoretically
to suggest that exhibitionists may be generally hypersexual interesting, the model does not account for possible mecha-
(Kafka & Hennen, 1999; Långström & Seto, 2006). nisms and seems difficult to test empirically. Based on clinical
In addition, unpublished data from my group suggest that, and preclinical data, Kafka (1997) introduced a new model that
among all 16,000 men convicted of sexual offences in Sweden relates paraphilias to paraphilia-related disorders—often refer-
between 1973 and 2004, 15% of those convicted of sexual red to as hypersexual, addictive, or compulsive—the primary
harassment offences (heavily dominated by exhibitionistic acts) difference being that the latter are non-deviant and legal. Comor-
had at least one independent prior or subsequent conviction of bidity patterns seem similar across paraphilias and hyper-
a contact sexual offence (rape, sexual coercion, or child moles- sexual disorders but there is currently no clear explanation as
tation). Studying criminal recidivism among more than 200 to why some individuals during certain circumstances actu-
convicted exhibitionists followed for an average of 13 years, ally offend against non-consenting partners. Swedish general
Firestone, Kingston, Wexler, and Bradford (2006) found that population data (Långström & Hanson, 2006) corroborate a
hands-on compared to hands-off sexual recidivists more often clear link between hypersexuality and paraphilic sexual behav-
had a criminal history of prior violent and criminal charges or iors (exhibitionism, voyeurism, sadism/masochism), equally
convictions. This argues for continued attention to the impor- strongly for both genders (odds ratios of 4–25 also when con-
tant difference between the paraphilia exhibitionism (with or trolling for various covariates).
without exhibitionistic behavior) and criminal offending involv- Without giving any specific references, Murphy and Page
ing exhibitionistic acts. As with the other potentially criminal (2008) recently suggested that exhibitionists who expose them-
paraphilias (voyeurism, frotteurism, sadism, pedophilia, and selves preferentially to adults and those who expose themselves
‘‘paraphilic rape’’), it is likely that the criminal offending to children might reflect different disorders. Murphy and Page
requires additional individual risk factors separate from the also cited a critique of diagnostic criteria for pedophilia and
paraphilic interest per se. other sexual disorders, such as their absence from DSM field
The study by Långström and Seto (2006) used interview trials (O’Donohue, Regev, & Hagstrom, 2000; see also Blan-
data from a national survey of 2,450 randomly selected 18- to chard, 2009). O’Donohue et al. questioned the reliability and
60-year-olds from the general population of Sweden. One item validity of paraphilic diagnoses, including how to interpret
specifically addressed the core behavioral feature of exhibi- terms like ‘‘recurrent,’’‘‘intense,’’ and ‘‘marked distress.’’
tionism—sexual arousal from exposing one’s genitals to a
stranger. A total of 76 (3.1%, 4.1% among men, and 2.1% Review of Previous DSM Criteria Sets
among women) participants reported at least one incident of
being sexually aroused by exposing their genitals to a stranger. DSM-III/DSM-III-R
Although effects sizes were weak to moderate, exhibitionism
was positively associated with being male and having more In the DSM-III-R (American Psychiatric Association, 1987),
psychological problems, lower satisfaction with life, greater the core criterion (A) for Exhibitionism (Over a period of
alcohol and drug use, and greater sexual interest and activity in at least 6 months, recurrent, intense sexual urges and sexually
general, including more sexual partners, greater sexual aro- arousing fantasies involving intense sexual arousal from expos-
usability, higher frequency of masturbation and pornography ing one’s genitals to an unsuspecting stranger) remained the
use, and greater likelihood of having had a same-sex sexual same as in DSM-III (American Psychiatric Association, 1980).
partner. Consistent with previous research from clinical sam- However, a qualifying diagnostic B criterion was added, as
ples of men with paraphilias, participants who reported any were true for all paraphilia diagnoses. This criterion was added
lifetime exhibitionistic behavior had substantially greater odds to emphasize that psychiatric disorders or diagnoses had to
of reporting other atypical sexual behavior, voyeuristic, sado- include acting out against others or substantial distress:
masochistic, or cross-dressing behavior.
A well-known conceptual model of paraphilias that includes B. The person has acted on these urges, or is markedly
exhibitionism is Freund’s notion of courtship disorders distressed by them.
(Freund & Blanchard, 1986; Freund et al., 1997), which includes
exhibitionism, voyeurism, and frotteurism but also telephone
scatologia and paraphilic rape. Very briefly, courtship disorder DSM-IV
is conceptualized as disturbances in one or more phases of the
statistically most common sequence of events in partner-based A. Over a period of at least 6 months, recurrent, intense sex-
sexual interactions. The four stages of this process are typically ually arousing fantasies, sexual urges, or behaviors involv-
described as finding an appropriate partner, approaching this ing the exposure of one’s genitals to an unsuspecting
potential partner, physical touching of the partner, and genital stranger.
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Arch Sex Behav (2010) 39:317–324 319
B. The fantasies, sexual urges, or behaviors cause clinically Equally sexually attracted to exposing genitals to both age
significant distress or impairment in social, occupational, groups (non-specific age preference).
or other important areas of functioning.
A concluding discussion at the end of this article contains
commentaries on the proposed criteria. However, note that the
DSM-V diagnostic criteria ultimately approved by the Ameri-
DSM-IV-TR
can Psychiatric Association may bear little or no resemblance
A. The core defining criterion remained the same as in DSM- to those suggested here.
IV (American Psychiatric Association, 1994).
An unintended consequence of the removal of‘‘the person has Voyeurism
acted on these urges…’’, from DSM-III-R to DSM-IV, was that
many clinicians erroneously interpreted the DSM-IV B criterion Method
to mean that those having paraphilias potentially hurting
others (including Exhibitionism, Voyeurism, and Frotteurism) See Exhibitionism.
had to have or admit to‘‘clinically significant distress or impair-
ment’’ for each paraphilia to be diagnosed (First & Frances, Results from Literature Review
2008). Hence, the DSM-IV-TR (American Psychiatric Asso-
ciation, 2000) reinstated that these paraphilias could be diag- Acts of voyeurism are probably the most common of poten-
nosed solely from the acting on the respective sexual urges. tially law-breaking sexual behaviors, according to clinical
B. The person has acted on these sexual urges, or the sexual studies (e.g., Abel et al., 1988; Bradford et al., 1992) and
urges or fantasies cause marked distress or interpersonal reports from general population samples (Långström & Seto,
difficulty. 2006; Templeman & Stinnet, 1991). Långström and Seto (2006)
examined the prevalence of the defining characteristic of
Note that no specification of ‘‘acted on’’ was supplied in voyeurism—self-reported sexual arousal from spying on others
DSM-IV-TR. In an attempt to improve this, I propose a min- having sex in a representative national sample in Sweden. A
imum number of three episodes needed for diagnosing each of total of 2,450 randomly selected 18- to 60-year-olds were inter-
the present Paraphilias/Paraphilic disorders in the uncooper- viewed and 191 (8%; 12% of the men, and 4% of women) par-
ative client. ticipants reported at least one incident of being sexually aroused
by spying on others having sex. A much smaller study of 60 male
non-convicted college students in a rural area of the U.S. sug-
Proposed DSM-V Diagnostic Criteria for Exhibitionistic
gested that 42% had secretly watched others in sexual situations
Disorder
(Templeman & Stinnet, 1991). When the students rank ordered
A. Over a period of at least 6 months, recurrent and intense their interest in less common sexual behaviors, voyeurism and
sexual fantasies, sexual urges, or sexual behaviors involv- frotteurism were the most popular. Similar high prevalences of
ing the exposure of one’s genitals to an unsuspecting voyeurism and frotteurism were also reported in a study of 61
stranger. adults of both genders in a small town in South India (Kar &
B. (ad modum Blanchard’s [2009] reasoning for Pedoheb- Koola, 2007).
ephilic Disorder). The person is distressed or impaired Despite these indications of considerable prevalence,
by these attractions, or has sought sexual stimulation from research has been ‘‘extremely limited’’ (Mann, Ainsworth,
exposing the genitals to three or more unsuspecting Al-Attar, & Davies, 2008). Perhaps this is because voyeurism
strangers on separate occasions. is relatively easy to relate to for many individuals and, there-
fore, does not elicit the same strong negative emotions as do
Since DSM diagnoses can be refined by the use of specifiers,
some of the other paraphilias. Importantly, however, there is
not necessarily mutually exclusive or cumulatively exhaustive
considerable overlap with other potentially criminal paraphi-
categories (American Psychiatric Association, 2000), I sug-
lias in clinical samples, particularly exhibitionism and sado-
gest consideration of the following:
masochism (Abel et al., 1988; Bradford et al., 1992; Fedora
Specify if: Sexually attracted to exposing genitals to pubes- et al., 1992; Freund et al., 1997; Gebhard et al., 1965). This
cent or prepubescent individuals (generally younger than seems to occur not only because of selection biases to clinical
age 15). and forensic settings. Långström and Seto (2006) found sub-
Sexually attracted to exposing genitals to physically mature stantial overlaps in their non-clinical population survey of
individuals (generally age 15 or older). adults of both genders in Sweden.
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320 Arch Sex Behav (2010) 39:317–324
Långström and Seto (2006) also investigated possible asso- B. The person has acted on these sexual urges, or the sexual
ciations between voyeuristic behaviors and various risk factors urges or fantasies cause marked distress or interpersonal
and correlates. Voyeuristic behaviors were weakly to moder- difficulty.
ately but positively associated with being male and having more
psychological problems, lower satisfaction with life, greater
Proposed DSM-V Diagnostic Criteria for Voyeuristic
alcohol and drug use, and greater sexual interest and activity in
Disorder
general, including more sexual partners, greater sexual arous-
ability, higher frequency of masturbation and pornography use, A. Over a period of at least 6 months, recurrent and intense
and greater likelihood of having had a same-sex sexual partner. sexually arousing fantasies, sexual urges, or sexual behav-
To examine whether non-clinical subjects would engage in iors involving the observing of an unsuspecting person
voyeurism, Rye and Meaney (2007) asked university students who is naked, in the process of disrobing, or engaging in
about the likelihood (0–100%) that they would secretly watch sexual activity.
an attractive person undress or two attractive people having B. (Discussed in more detail by Blanchard [2009] and exem-
sex. When the risk of being caught was manipulated from 0 to plified by Pedohebephilic Disorder). The person is dis-
25%, the mean likelihood fell from 84 to 61% among men and tressed or impaired by these attractions, or has sought sex-
from 74 to 36% in women. This bears on the ‘‘incidental’’ vs. ual stimulation from observing three or more unsuspecting
‘‘patterned’’subdivision suggested by Gebhard et al. (1965) in persons who are naked, disrobing, or engaging in sexual
their study of 56‘‘peepers’’or voyeurists. The former (43% of activity on separate occasions.
their sample) might be less planning and more opportunistic
A concluding discussion at the end of the article comments on
and may be less likely to fulfill DSM criteria for Voyeurism
the proposed criteria.
despite having been convicted in court for a voyeuristic act.
Review of Previous DSM Criteria Sets

Frotteurism
DSM-III/DSM-III-R
Method
A. In the DSM-III-R, the core criterion for Voyeurism (Over
a period of at least 6 months, recurrent, intense sexual See Exhibitionism.
urges and sexually arousing fantasies, involving the obser-
vation of an unsuspecting person who is naked, disrobing, Results from Literature Review
or engaging in sexual activity) remained the same as in
DSM-III. The French verb ‘‘frotter’’ means ‘‘rubbing’’ or ‘‘friction,’’ and
the associated nouns are ‘‘frottage’’ and ‘‘frotteur’’ (the person
A B Criterion was added: doing frottage). Krueger and Kaplan (2008) and others credit
B. The person has acted on these urges, or is markedly dis- German psychiatrist von Krafft-Ebing for being the first men-
tressed by them. tioning frotteurism in Psychopathia Sexualis. However, frot-
teurism has not been a subject of much clinical or scientific
DSM-IV interest. Prevalence-wise, data from Kafka and Hennen (2002),
Bradford et al. (1992), and Abel et al. (1988) suggest that 10–
A. Over a period of at least 6 months, recurrent, intense sex- 14% of men in clinical outpatient settings for paraphilias and
ually arousing fantasies, sexual urges, or behaviors involv- paraphilia-related disorders have committed frotteuristic acts.
ing the act of observing an unsuspecting person who is No representative survey has provided prevalence estimates of
naked, in the process of disrobing, or engaging in sexual frotteurism in the general population. Two small studies sug-
activity. gested high rates among 61 unclearly recruited adult men and
B. The fantasies, sexual urges, or behaviors cause clinically women in a little town in South India (Kar & Koola, 2007) and
significant distress or impairment in social, occupational, in a convenience sample of 60 male college students in a rural
or other important areas of functioning. area of the U.S. (Templeman & Stinnet, 1991). Krueger and
Kaplan (2008) further noted the lack of published accounts of
DSM-IV-TR female frotteurs. The relatively recent addition of Frotteurism
by the American Psychiatric Association to DSM-III-R may
A. The core defining criterion remained the same as in DSM- have contributed to the lack of data. The disorder did not
IV. appear in the second edition (DSM-II; American Psychiatric
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Arch Sex Behav (2010) 39:317–324 321
Association, 1968) and was first introduced as an ‘‘atypical DSM-IV-TR

paraphilia’’ in the DSM-III.
A. The core defining criterion remained the same as in DSM-
Comorbidity is very common; among 144 frotteurs studied
IV.
by Freund et al. (1997), 68% also had another paraphilic behav-
B. The person has acted on these sexual urges, or the sexual
ior, usually exhibitionism and voyeurism, two other courtship
urges or fantasies cause marked distress or interpersonal
disorders. Templeman and Stinnet (1991) obtained similar results
difficulty.
in their convenience sample of 60 male college students.
Lussier and Piché (2008) cited other researchers who argued
that frotteurism is strongly reinforced behaviorally by imme- Proposed DSM-V Diagnostic Criteria for Frotteuristic
diate sexual gratification with very little cost and investment Disorder
(albeit at the expense of another person). In addition, Lussier
and Piché used developmental psychology references to sug- I suggest that the diagnostic Criterion A for Frotteurism be
gest a specifier related to the age of onset of frotteurism: child- preserved since there is very limited data to suggest otherwise.
hood or adolescence vs. young adulthood. Based on case stud- At the same time, it is not surprising that it was first with the
ies, Horley (2001) argued that frotteurs could be seen as timid DSM-III that Frotteurism was specified as a paraphilia on its
or nonassertive rapists, with the likelihood of committing a own. It was probably its relevance to decision-making in
more serious sexual assault given the right set of circumstances criminal justice rather than in clinical settings that motivated
(e.g., sufficient courage, a very submissive victim). However, its emergence as a specified paraphilia.
we lack sufficient data to either support or refute this suggestion.
A. Over a period of at least 6 months, recurrent and intense
sexually arousing fantasies, sexual urges, or sexual behav-
iors involving touching or rubbing against a nonconsent-
Review of Previous DSM Criteria Sets ing person.
B. (Discussed in more detail by Blanchard [2009] and
DSM-III exemplified by Pedohebephilic Disorder). The person is
distressed or impaired by these attractions, or has sought
Frotteurism was considered an atypical paraphilia. sexual stimulation from touching or rubbing against three
or more nonconsenting persons on separate occasions.
DSM-III-R
Commentary on Proposed Criteria
In the DSM-III-R, Frotteurism was for the first time opera-
tionally defined as a specific paraphilia:
Renaming the Diagnoses
A. Over a period of at least 6 months, recurrent, intense
sexual urges and sexually arousing fantasies, involving In agreement with Blanchard (2009) and Kafka (2009), I find it
touching and rubbing against a nonconsenting person. It idiosyncratic that Exhibitionism, Voyeurism, and Frotteurism
is the touching, not the coercive nature of the act, that is are not followed by the term‘‘Disorder’’if the individual both
sexually exciting. admits to (or is indirectly observed to have) the respective core
B. The person has acted on these urges, or is markedly defining DSM-IV-TR characteristic (Criterion A) and has
distressed by them. acted on these sexual urges, or is distressed or impaired inter-
personally as a result of such urges and fantasies (according to
Criterion B). Therefore, for reasons of conceptual clarity and
consistency with other sections of the DSM, I suggest the intro-
duction of the terms Exhibitionistic, Voyeuristic, and Frot-
DSM-IV
teuristic Disorder, respectively, for those who also fulfill Cri-
A. Over a period of at least 6 months, recurrent, intense terion B (see also Cantor, Blanchard, & Barbaree, 2009).
sexually arousing fantasies, sexual urges, or behaviors The use of the present terms Exhibitionism, Voyeurism, and
involving touching and rubbing against a nonconsenting Frotteurism should be abandoned for diagnostic purposes.
person. However, they might be used for research and development
B. The fantasies, sexual urges, or behaviors cause clinically purposes, but only for those who do not fulfill Criterion B (and
significant distress or impairment in social, occupational, hence do not fulfill the full set of diagnostic criteria for a DSM-
or other important areas of functioning. V Paraphilic Disorder).
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322 Arch Sex Behav (2010) 39:317–324
Duration of Signs and Symptoms Further Reflections on Diagnostic Criteria
Albeit somewhat arbitrary in character (cf. O’Donohue et al., The similarities between ‘‘courtship disorder’’ paraphilias
2000), there is no empirical support to suggest any alteration of Exhibitionism/Exhibitionistic Disorder, Voyeurism/Voyeuris-
the qualifying phrase ‘‘over a period of at least 6 months’’ for tic Disorder, and Frotteurism/Frotteuristic Disorder and the little
any of the three paraphilias reviewed here. (new) empirical data there are for these entities particularly from
community-based studies (for exceptions, see Långström &
Seto, 2006; Templeman & Stinnet, 1991), but also from clin-
Altered Criterion B ical, and convenience samples, led me to try to synthesize my
impressions and to coordinate my suggestions for these three
I suggest consideration of similar attempts to quantify the paraphilias.
extent of paraphilic behavior for those paraphilias that are One common criticism of current conceptualizations of
potentially criminal (pedophilia, exhibitionism, voyeurism, frot- the paraphilias, particularly sadomasochism and fetishism,
teurism, and sadism) like those presented by Blanchard (2009) focuses on that the diagnostic criteria address sexual behavior
for non-cooperative individuals with possible Pedohebephilic which many people deem non-pathologic or normal, although
Disorder (see also O’Donohue et al., 2000). To my knowledge, not in a strict statistical sense. These critics often refer to the
there are no published data that could directly advise on such removal of homosexuality from the DSM-II in 1973, and argue
behavioral determinants for the paraphilias reviewed here. that BDSM (Bondage, Dominance, Submission/Sadism, and
However, the DSM-IV-TR used‘‘has acted upon’’as a vaguer Masochism) behaviors should be similarly depathologized
behavioral indicator, and I suggest that three or more victims (for a review, see Krueger, in press). Importantly, however,
on separate occasions as a threshold for Exhibitionistic, Voy- several other mental disorders in the DSM-IV-TR have criteria
euristic, and Frotteuristic Disorder. The rationale is to improve that are more or less statistically normal on their own (or at
interrater reliability and validity. The exact number is chosen least not pathological) but without attracting similar criticism.
to balance false negatives (i.e., inaccurately diagnosing indi- For example, the DSM-IV-TR A Criterion ‘‘Recent use of
viduals not distressed or impaired by their attractions, or unwill- alcohol’’designates a quite common experience. However, it is
ing to report them, as not having a paraphilic disorder from first with the additional presence of B and C Criteria denoting
behavior only, because of a too high threshold) against false distress or impairment that the necessary criteria for Alcohol
positives (i.e., incorrectly diagnosing someone as having a Intoxication (303.00) are fulfilled. Likewise, although less
paraphilic disorder from behavior only because of a too low common than recent use of alcohol, the A criterion‘‘A distinct
threshold). Three or more victims on separate occasions is period of persistently elevated, expansive, or irritable mood,
based on typical behaviors of individuals with these paraph- lasting throughout at least 4 days, that is clearly different from
ilias (e.g., Abel et al., 1987), and base rates for core behaviors the usual nondepressed mood’’ is not a DSM-IV-TR psychi-
judged from epidemiological data (e.g., Långström & Seto, atric disorder on its own. But when additional A Criterion-
2006; Templeman & Stinnet, 1991). However, importantly, related symptoms and impairment (B, C, and D Criteria) are
the suggestion of these thresholds for DSM-V diagnostic pur- present, the necessary criteria for Hypomanic episode might
poses is not a comment on the varying ways used to define be fulfilled. Using analogous reasoning as critics opposed to
unlawful conduct in different judicial traditions. Nor does it sexual behaviors perceived as normal being mentioned in
imply that I want to minimize victim experiences of such acts. diagnostic systems for mental disorders, a number of other
diagnoses would have to be seriously considered for removal
on similar grounds. In fact, recent lobbying from sexual rights
Age Specifier for Targets of Exhibitionistic Fantasies, organizations led the Swedish National Board of Health and
Urges, or Behaviors Welfare to unilaterally delete paraphilias fetishism, sadomas-
ochism, and transvestism from the latest Swedish version of
Although not backed by any specific study, but suggested from the International Statistical Classification of Diseases and
some research (e.g., Gebhard et al., 1965), this specifier might Related Health Problems (ICD-10) (World Health Organiza-
have additional diagnostic value. Since several reports suggest tion, 1992) as of January 1, 2009 (Associated Press, 2008).
frequent co-morbidity among the paraphilias (Abel et al., Whereas clinicians in Sweden need to find other ways to
1988, Bradford et al., 1992; Fedora et al., 1992; Freund et al., diagnose and occasionally treat individuals with several of the
1997; Gebhard et al., 1965), this specifier attempts to draw deleted, but arguably still existing, disorders, another option
attention to possible underlying or comorbid pedophilia. How- could have been to strengthen distress and impairment criteria.
ever, the use of specifiers with Exhibitionistic Disorder should DSM and ICD nosologies for the paraphilias are partly dif-
not prevent the clinician from independently considering pos- ferent and distress and impairment criteria undoubtedly much
sible co-occurring Pedohebephilic Disorder. less pronounced in ICD-10 (cf. Reiersøl & Skeid, 2006).
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Arch Sex Behav (2010) 39:317–324 323
Many individuals who practice variant sexual behaviors in Acknowledgments Niklas Långström is funded by the Swedish
a safe and consensual manner (typically recreational BDSM Research Council-Medicine. The author is a member of the DSM-V
Workgroup on Sexual and Gender Identity Disorders (Chair, Kenneth J.
practitioners) appear to neither experience distress nor suffer Zucker, Ph.D.). I wish to acknowledge the valuable input received from
significant psychosocial impairment (Långström & Hanson, the other members of the Paraphilias subworkgroup (Ray Blanchard,
2006; Richters, de Visser, Rissel, Grulich, & Smith, 2008). In Marty Kafka, and Richard Krueger) and Kenneth J. Zucker. Reprinted
other words, this strongly indicates that they neither fulfill cur- with permission from the Diagnostic and Statistical Manual of Mental
Disorders V Workgroup Reports (Copyright 2009), American Psychi-
rent DSM-IV-TR diagnostic criteria for paraphilias nor will do atric Association.
so with the current suggestions for DSM-V. One of the delicate
challenges for revisions of the DSM (and ICD) diagnostic sys-
tems is to minimize false positives, by not diagnosing those References
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Arch Sex Behav (2010) 39:325–345
DOI 10.1007/s10508-009-9586-3
ORIGINAL PAPER
The DSM Diagnostic Criteria for Sexual Sadism

Richard B. Krueger
Published online: 8 December 2009

Abstract I reviewed the empirical literature for 1900–2008 (Wright, 2006). Indeed, Sweden recently took the step of
on the paraphilia of Sexual Sadism for the Sexual and Gender removing transvestism, fetishism, and sadomasochism from
Identity Disorders Workgroup for the forthcoming fifth edition its official list of diseases and mental disorders (The Asso-
of the Diagnostic and Statistical Manual of Mental Disorders ciated Press, 2008) to avoid such discrimination. Further,
(DSM). The results of this review were tabulated into a general although the diagnosis of Sexual Sadism is widely used for
summary of the criticisms relevant to the DSM diagnosis of forensic purposes, it is not reported in diagnostic codes for
Sexual Sadism, the assessment of Sexual Sadism utilizing the outpatient ambulatory care. Survey information from the U.S.
DSM in samples drawn from forensic populations, and the National Ambulatory Medical Care Survey was obtained for
assessment of Sexual Sadism using the DSM in non-forensic outpatient visits for diagnoses involving the sexual and gen-
populations. I conclude that the diagnosis of Sexual Sadism der identity disorders (W. Narrow, personal communication,
should be retained, that minimal modifications of the wording December 16, 2008). This survey reported on the occurrence
of this diagnosis are warranted, and that there is a need for the of diagnoses for a total of 25,150,180 visits to psychiatrists,
development of dimensional and structured diagnostic instru- 18,306,540 visits to urologists, 333,873,400 visits to general/
ments. family/internal medicine physicians, and 69,435,650 to obste-
tricians/gynecologists. Strikingly, no visits with the diagnoses
Keywords Paraphilias Sexual Sadism Sexual of Sexual Sadism or Sexual Masochism were recorded. This
Masochism Paraphilic coercive disorder DSM-V may reflect concerns about stigmatizing individuals with the
application of these diagnoses, as well as absence of presen-
tation of individuals for treatment for these problems.
Introduction This article will review the changes in narrative and the
critiques of the diagnostic entity of Sexual Sadism, examine
The paraphilic diagnoses have been criticized as not consti- existing studies that have used the DSM criteria for Sexual
tuting mental illness or involving society’s use of mental Sadism, and review in particular studies that have examined
health professionals to constrain deviant behavior (Green, the reliability, validity, and discriminant validity of such cri-
2002a, b; Moser, 2001, 2002) with some moving beyond mere teria. Because most of the studies have been conducted on
criticism to recommending frank removal of the paraphilias forensic populations (consisting of subjects who have been
from the DSM (Moser & Kleinplatz, 2005). The diagnoses of arrested or incarcerated for sexual crimes) who one might
Sexual Sadism and Sexual Masochism, in particular, have expect could differ substantially from non-forensic popula-
been cited as pathologizing, stigmatizing, and discriminating tions, studies done using the DSM on forensic populations will
against individuals who engage in alternative sexual practices be examined separately from studies done on non-forensic
populations. Finally, discussion and recommendations will be
based on the use of this diagnosis for both populations.
R. B. Krueger (&)
Further, for ease of reference, several tables have been
Sexual Behavior Clinic, New York State Psychiatric Institute,
1051 Riverside Drive, Unit 45, New York, NY 10032, USA developed. Table 1 contains criticisms relevant to Sexual
e-mail: [email protected] Sadism, Table 2 lists studies that have utilized DSM-criteria in
123
326 Arch Sex Behav (2010) 39:325–345
exclusively forensic populations, and Table 3 contains studies DSM-III-R (American Psychiatric Association, 1987) mod-
that have been conducted on mixed (consisting of both foren- ified this to require: A. Over a period of at least six months,
sic and non-forensic) populations. Finally, also included are recurrent intense sexual urges and sexually arousing fantasies
Appendixes listing all of the previous DSM criteria sets involving acts (real, not simulated) in which the psychological
for Sexual Sadism and commentary (Appendix 1), along with or physical suffering (including humiliation) of the victim is
ICD-9 criteria (World Health Organization, 1989), ICD-10 sexually exciting to the person; B. The person has acted on
criteria (World Health Organization, 1992), and ICD-10 these urges, or is markedly distressed by them (see Appendix 1).
research criteria (World Health Organization, 1993) for sado- DSM-IV (American Psychiatric Association, 1994) added
masochism (Appendix 2). ‘‘behaviors’’to the Criterion A requirement of sexual urges and
sexual arousing fantasies, and added the conjunctive ‘‘or’’ so
that any of these entities (sexually arousing fantasies, sexual
Method urges, or behaviors) was sufficient in Criterion A and changed
Criterion B, removing the terminology that a person had‘‘acted’’
Consisted of a literature search by a librarian at the New York on these, and replacing this with the criteria that these caused
State Psychiatric Institute using the search terms of ‘‘sexual ‘‘clinically significant distress or impairment in social, occupa-
masochism,’’ ‘‘sexual sadism,’’ ‘‘sadomasochism,’’ domination, or other important areas of functioning’’(see Appendix 1).
tion,’’‘‘bondage,’’‘‘BDSM,’’‘‘perversion,’’‘‘paraphilia,’’‘‘sex- Finally, DSM-IV-TR (American Psychiatric Association,
ual homicide,’’ ‘‘sexual murder,’’ ‘‘lust murder,’’ and ‘‘sex 2000) returned to the criteria that an individual had‘‘acted’’on
killer’’of PubMed from 1966 through December 15, 2008, and these urges with a nonconsenting person, and continued with
of PsychInfo from 1900 through December 15, 2008. Addi- the criteria of‘‘marked distress or interpersonal difficulty’’(see
tionally, all of the prior DSM manuals were consulted as well Appendix 1).
as ICD-9 and ICD-10. Articles were culled and attention was This last change, returning to the criteria of DSM-III-R, was
focused on articles using the DSM to make diagnoses of Sex- to avoid the unintended consequence of the removal of the
ual Sadism or offering critiques of the diagnostic criteria for requirement that an individual had acted on such urges in
Sexual Sadism or the paraphilias. Discussion of this literature DSM-IV. This deletion would, in the case of an individual with
and the diagnostic criteria were engaged in with colleagues. pedophilia, for instance, have not allowed for a diagnosis of
pedophilia to be made for an individual who had acted on such
urges, but was not distressed by them or socially or occupa-
Results tionally impaired by them (First & Pincus, 2002; Hilliard &
Spitzer, 2002). The editors of DSM-IV, regarding the changes
Summary of Evolution of Diagnostic Criteria for Sexual in sexual sadism from DSM-IV to DSM-IV-TR, went on to
Sadism in the DSM say:
Because some cases of sexual sadism may not involve
Sexual Sadism has been incorporated into the DSM manuals
harm to a victim, such as inflicting humiliation on a
since its inception (American Psychiatric Association, 1952). In
consenting partner, the wording for sexual sadism
DSM-I, this was part of the diagnosis of ‘‘Sexual Deviation,’’
involves a hybrid of the DSM-III-R and DSM-IV text.
which was reserved for ‘‘deviant sexuality…not symptomatic
The DSM-IV-TR version states: ‘‘The person has acted
of more extensive syndromes,’’ and was referred to as ‘‘sexual
on these urges with a nonconsenting person, or the urges,
sadism (including rape, sexual assault, mutilation)’’(pp. 38–39)
sexual fantasies, or behaviors cause marked distress or
(see Appendix 1). Sadism was continued as a ‘‘sexual devi-
interpersonal difficulty.’’ (p. 291)
ation’’in DSM-II (American Psychiatric Association, 1968) and
masochism was added as a separate diagnosis (see Appendix 1). In a later communication, the editors of the DSM-IV-TR
DSM-III (American Psychiatric Association, 1980) added (First & Frances, 2008) indicated that the addition of the phrase
specific diagnostic criteria, allowing a diagnosis to be made ‘‘or behaviors’’to Criterion A in DSM-IV had allowed forensic
with one of the following: (1) on a nonconsenting partner, the evaluators to conclude that an individual who had committed a
individual has repeatedly intentionally inflicted psychological sexual offense (e.g., rape) would qualify for the diagnosis of a
or physical suffering in order to produce sexual excitement mental disorder solely on the basis of repeated acts of sexual
or (2) with a consenting partner, the repeatedly preferred or violence alone, without establishing the underlying condition
exclusive mode of achieving sexual excitement combines of deviant urges or fantasies requisite to establishing that a
humiliation with simulated or mildly injurious bodily suffer- mental illness existed and they recommended removing the
ing, or (3) on a consenting partner, bodily injury that is exten- phrase ‘‘or behaviors’’ from the DSM-IV criteria. They cau-
sive, permanent, or possibly mortally is inflicted in order to tioned that ‘‘tinkering with criteria wording should be done
achieve sexual excitement (see Appendix 1). only with great care and when the advantages clearly outweigh
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Arch Sex Behav (2010) 39:325–345
Table 1 Summary of criticisms relevant to the DSM diagnosis of Sexual Sadism
Author Source Diagnostic criteria criticized Comments/conclusions
Tallent (1977) Peer reviewed article Paraphilias Paraphilias like homosexuality should be removed from the DSM; they
represent value judgments only and not scientifically established
criteria
Silverstein (1984) Peer reviewed article Paraphilias Paraphilias like homosexuality should be removed from the DSM; they
represent value judgments only and not scientifically established
criteria
Suppe (1984) Peer reviewed article DSM-III and the paraphilias Sexual deviation is not a diagnostic entity. Paraphilias should be
removed from DSM. Burden of proof that these are personally or
socially harmful rests with advocates of DSM: deletion may not
change social attitudes
Grove et al. (1981) Peer reviewed article All DSM diagnoses Diagnostic reliability had improved in psychiatry because of carefully
constructed interview schedules and lists of diagnostic criteria, along
with rigorous training of raters; much work remained undone
Kirk and Kutchins (1994) Peer reviewed article All DSM diagnoses Reanalyzed data gathered in original DSM-III field trials and suggested
that earlier claims of Interrater reliability were overstated
Gert (1992) Peer reviewed article DSM-III-R; all paraphilias Liked definition of mental disorder; would change definition of
paraphilia, specifically transvestic fetishism, to be consistent with
definition of mental disorder
Grubin (1994) Editorial Broad commentary on No specific commentary on diagnostic criteria or DSM; presented a
sexual sadism board review of sadism and the importance of a history of fantasy,
escalation in behavioral rehearsals, and other factors
Schmidt (1995) Book chapter Broad discussion of all of He summarized that the literature reviews completed for DSM-IV
Schmidt et al. (1998) DSM sexual disorders revealed a paucity of data supporting the scientific conceptual
including paraphilias underpinning of current diagnostic terminology regarding sexual
psychopathology
Campbell (1999) Peer reviewed article All DSM diagnoses Evidentiary reliability of DSM-IV consistently flounders because of lack
Campbell (2004) Book of Interrater reliability data. Later books suggested extended this to
sex offender assessment
Campbell (2007) Book
McConaghy (1999) Peer reviewed article Broad review of He suggested that the DSM-IV stated that the severity of sadistic acts
sexology; all of DSM increased over time; that while this may apply to serial or sadistic
murderers, who were extremely rare, the lack of presentation for
treatment of subjects who practiced S&M suggested that this was
more benign. He said that this statement regarding progression was
made towards sadism generally, and was misleading. He suggested
that in view of the lack of a relationship of S&M with psychiatric
pathology, as was the case with homosexuality, it would be reasonable
that sadomasochism should also not be classified as a disorder
Moser (2001) Book chapter All of DSM paraphilias Argues DSM ‘‘pathologizes’’ individuals who have nonstandard sexual
interests despite a lack of research establishing difference in
123
functioning; presents broad review and criticism; he suggests the

classification of ‘‘Sexual Interest Disorder’’
327
328
123
Table 1 continued
Doren (2002) Book All of DSM paraphilias He raises the possibility of a paraphilia not otherwise specified, or
nonconsensual and concludes that the lack of plethysmographic data
demonstrated differential sexual arousal by rapists to rape or violent
clues does not allow for a numerical threshold criteria for diagnosis a
paraphilia (such as an individual with a certain threshold number of
rapes would demonstrate consistent arousal to rape stimuli in the
plethysmographic laboratory)
Marshall and Kennedy (2003) Peer reviewed article Broad review of diagnostic They said that the definition of sadism varied considerably in what
criteria of sexual sadism was thought necessary to provoke sexual arousal, and that the
operationalization of these definitions was difficult. They
recommended abandoning the present diagnostic criteria and shifting
to a dimensional approach to defining sadism
Berner et al. (2003) Peer reviewed article ICD-10 and DSM-IV Current studies on differently selected clinical samples reveal changed
distribution with masochism prevailing in outpatient facilities and
sadism in forensic settings; no survey data were presented to support
this impression, however
Moser and Kleinplatz (2005) Peer reviewed article All with focus on DSM-IV-TR Asserted there were many factual mistakes in the text; that paraphilias
were not mental disorders; that inclusion of paraphilias in the DSM
facilitated discrimination and harm to people with variant sexual
interests; and that for consenting adults it was not their sexual interests
but the manner in which they were manifest that was a problem and
more appropriate focus for therapy
Spitzer (2005) Peer reviewed article All with focus on DSM-IV-TR Contended that‘‘medical disorder’’could be applied to human behavior;
said that Drs. Moser and Hill had not presented a single case, child or
adult, of someone who had been harmed by being given a diagnosis of
a paraphilia
Fink (2005) Peer reviewed article All with focus on DSM-IV-TR Expressed that there must be some way of differentiating between the
normal and abnormal ways in which people get aroused, excited and
fulfilled. He thought it was important to retain paraphilic diagnosis‘‘in
order to save some people from jail and others from themselves’’
Kleinplatz and Moser (2005) Peer reviewed article All with focus on DSM-IV-TR Maintained that Spitzer and Find did not dispute their analysis of the
problems with the DSM-IV-TR criteria for paraphilias and that
Arch Sex Behav (2010) 39:325–345

conservative organizations flagrantly misrepresented their statements
and intent, the symposium it was presented at and the APA. They
stated that public opinion and not science were the main reason to keep
the paraphilias in DSM
Marshall and Hucker (2006) Peer reviewed article Both DSM and ICD They summarized their studies demonstrating poor agreement between
rating psychiatrists; they wrote that no one had developed satisfactory
specific stimuli for phallometric testing designed to detect sexual
arousal to sadistic acts, and presented a 17 item Sexual Sadism Scale
Reiersøl and Skeid (2006) Peer reviewed article ICD-10 The ICD diagnoses of Fetishism, Transvestic fetishism and
Sadomasochism are outdated and not up to the scientific standards of
the ICD manual. They stigmatize minority groups
Arch Sex Behav (2010) 39:325–345 329
approach. They wrote that for the time being they had decided to use
Reviewed aspects of sexual sadism and suggestions to use a dimensional
psychological pain and physical suffering? Beware of causal relations

the risks, both because of the potentially unforeseen conse-
Why 6 months?; what do ‘‘recurrent,’’ intense,’’ mean? Can one discuss

urges separate from fantasies? Why distinguish between real and
quences of rewording criteria and because of the disruptive
nature of all changes’’ (pp. 1240–1241).
simulated acts? Why is humiliation identified in addition to

the DSM classification system, not the dimensional one
and correlations derived from samples of convenience

Review of Criticisms Relevant to Sexual Sadism
(See Table 1)
Tallent (1977) suggested that the paraphilias, like homosex-

uality, should be removed from the DSM, because they rep-
resented only value judgments about sexual behavior and not
disease. These arguments were echoed by Suppe (1984) and
Silverstein (1984).
Comments/conclusions
Grove, Andreasen, McDonald-Scott, Keller, and Shapiro

(1981) reviewed existing literature on the reliability of psychi-
atric diagnoses, and opined that ‘‘Carefully constructed inter-
view schedules and lists of diagnostic criteria, together with
rigorous training of raters, have caused a quantum jump in
the magnitude of psychiatric reliability in the last decade’’ (p.
412). Kirk and Kutchins (1994) reanalyzed data gathered from
DSM-III field trails, and suggested that claimed success was
equivocal.
Gert (1992) opined that the DSM-III-R definition of mental
disorder as requiring the suffering or increased risk of suffering
Diagnostic criteria criticized
was defensible and that the definition of paraphilias should be

changed to include this. Grubin (1994) in an editorial on
Sexual Sadism did not offer criticism of the criteria, but rather
said that Sexual Sadism was important to study.
DSM-IV-TR
Use of DSM
Schmidt (1995) and Schmidt, Schiavi, Schover, Segraves,

and Wise (1998) on the DSM-IV Sexual Disorders Workgroup
reported that literature reviews completed for DSM-IV
revealed a paucity of data supporting the scientific concep-
tual underpinning of current diagnostic terminology for sexual
psychopathology.
Campbell (1999) criticized all of the DSM-IV because of
lack of interrater reliability data. In later books, Campbell
Peer reviewed article
(2004, 2007) reviewed the use of the DSM in the forensic

assessment of sexual offenders and concluded that there were
many issues, including lack of interrater reliability.
Source
In a review of issues relevant to sexology, McConaghy

(1999) pointed out that the DSM-IV made the statement that
the severity of sadistic acts increased over time, but said that,
while this may apply to serial or sadistic murderers, the evi-
dence for the usual practitioners of S & M, who presented
only rarely for medical treatment, suggested that this was not
the case for them. Yet, he indicated that in the DSM-IV the
Kirsch and Becker (2007)
statement regarding progression was made with respect to

sadism in general. He suggested that, in view of the lack of a
Table 1 continued
relationship of S & M with psychiatric pathology, that sado-

Fedoroff (2008)
masochism, like homosexuality, should not be classified as a

DSM disorder.
Author
Moser (2001) offered a review of criticisms of paraphi-

lias, and suggested that the DSM continued to pathologize
123
330
123
Table 2 Summary of studies involving assessment of Sexual Sadism utilizing the DSM in samples drawn from forensic populations
Study Design Number of and source Diagnostic Methods of diagnosis and data Results Comments/conclusions
of subjects criteria used used
Packard and Chart review of defendants 95 DSM-III Semi structured interview Only 6.3% had a No Interrater reliability computed;
Rosner charged with at least 1 sexual format; 2 evaluators for each diagnosis of a no further delineation of which
(1985) offense during 1980–1983; individual paraphilia paraphilia the subject had
no control group
Langevin Cases selected because they 13 sex killers compared with ICD-9 diagnosis Interview, information from 75% of sex killers had Phallometric testing attempted
et al. (1988) had murdered someone in 13 nonhomocidal sexually history; variable sexual sadism; 0% of on 17 cases; 9 refused
conjunction with erotic aggressive men information on the subjects the sexual aggressive
arousal
Dietz et al. Chart review of information of 30 Presumably Operationalized to 3 judges 77% engaged in sexual Concluded that necessary condition
(1990) especially selected sexually DSM-III-R, agreeing that criminal was bondage; 100% for a diagnosis of sexual sadism is
sadistic criminals; no control although not sexually aroused to images engaged in intentional the presence of sexually arousing
group explicitly of suffering or humiliation torture of victim fantasies about the kinds of
stated on at least 6 occasions over sadistic behavior individuals
6 months engaged in
Yarvis (1990) Chart review of interviews of 100 DSM-III Chart Review It appears that 3 of 10 Charts reporting data were not
homicide offenders homicide/rape cases entirely clear
interviewed by the author received diagnosis of
between 1980 and 1988 sexual sadism
Bradford et al. Review of information 443 None 11 items from the Male Sexual Sadism not mentioned; Recommended reviewing diagnostic
(1992) collected on males admitted History Questionnaire 30 subjects admitted criteria for paraphilias and
consecutively to Sexual developed at the Clarke to rape and 56 to suggested the classification of a
Behaviors Clinic at Royale attempted rape ‘‘coercive paraphilia’’ as a within
Ottawa Hospital the spectrum of paraphilic
disorders
Gratzer and Chart review comparing 30 30 sexual sadists from Dietz DSM III-R Chart review, document review Offender and offense Further research to better delineate
Bradford sexually sadistic criminals study above and 29 characteristics not the characteristics of sexual
(1995) from a study by Dietz with 29 sexually sadistic criminals specific to sexual sadism necessary
sexually sadistic criminals and 28 nonsadistic sexual sadism
and 28 nonsadistic sexual offenders at Royal Ottawa
offenders Hospital
Yarvis (1995) Chart review of interviews by 78 men charged with DSM-III criteria Initial interview notes then 0% of murderers, 6.5% Sexual diagnoses found among sex
Arch Sex Behav (2010) 39:325–345

author of men interviewed homicide, 92 with sexual only recorded onto a 229 item of rapists, and 30% offenders, with sexual murderers
between 1980 and 1993 assault, and 10 men precoded questionnaire of rape/murderers having highest prevalence of
charged with sexual diagnoses with sexual sexual sadism
assault who killed their sadism
victims
Arch Sex Behav (2010) 39:325–345
Table 2 continued
Geberth Review of case histories Authors reviewed cases in DSM-IV case history Review of information from the 68 cases met definitions of Authors concluded that ‘‘DSM-
and of 232 serial killers media and FBI violent evaluation protocol Associated Press and United antisocial personality IV permitted the accumulation
Turco crimes database for serial examining for Press International and the FBI disorder and sexual of data, such as neurological-
(1997) murderers; of 387 cases, antisocial personality National Center for the sadism biological information in a
248 violated their victims disorder and sexual Analysis of Violent Crime; meaningful manner without
sexually, 232 males sadism case history evaluation changing the psychodynamic
finally identified protocol based on DSM-IV perspective’’
criteria
Firestone Review of chart 48 DSM-III Chart review, phallometry, other 75% of homicidal Diagnoses were made by
et al. information on 48 psychiatric tests, history offenders and 2 percent psychiatrists before they had
(1998) homicidal sex offenders of incest offenders met psychological test scores or
assessed between 1982 criteria for sexual phallometric assessment
and 1992 compared with sadism results
group of incest offenders
Raymond Interview of volunteers 45 males with pedophilia DSM-IV Interview; prospective study 2 of 45 had sexual sadism;
et al. with pedophilia using, using structured diagnostic 0 had sexual masochism
(1999) among other things instruments
sexual SCID
Berger Prospective study 70 consecutively admitted DSM-III-R Consensus of clinical interviews 28 (42%) had diagnosis of One of the better designed
et al. male adult sex offenders performed separately by two sexual sadism; 19% studies; it was prospective and
(1999) investigators assisted by admitted to sadistic a structured interview was
separate informal interview fantasies during used to assess personality
with patient’s individual masturbation; only 6% disorders
therapist said that they carried out
sadistic activities during
intercourse or
masturbation
Holt et al. Prospective study; clinical 100 files randomly drawn DSM-IV Interviewers made diagnosis On 3 of 41 had sexual Too small a number of
(1999) interviews and other from 400 inmates; 75 based on threshold criteria sadism individuals with sexual sadism
testing were conducted records complete enough from DSM-IV, and data from to analyze further
prospectively; chart to invite inmate to the subject’s prison file and
information used participate; 41 subjects clinical interview
included
Stone Culled 98 biographies from 98 biographies Not specified Review of published information 18 of 98 were reported as
(2001) publically available having the paraphilia of
information ‘‘sexual sadism with
orgasm’’
123
331
332
123
Table 2 continued
Marshall, Chart review and Charts of 59 subjects DSM-III-R and DSM-IV Offense characteristics; self- No difference between Questioned the adequacy
Kennedy, comparison of features reviewed and coded report; phallometry; those diagnosed with of the DSM criteria for
and Yates obtained by chart review by 2 psychiatrists diagnosis made by sexual sadism and those sexual sadism; also
(2002) of a group of men psychiatrist without this diagnosis indicated that one
diagnosed with sexual explanation could have
sadism and without been poor diagnostic
sexual sadism practices in correctional
system of Canada
Marshall, Vignettes sent to different 12 vignettes to 24 Not explicitly stated Diagnosis made by Adjusted percentage of Poor agreement between
Kennedy, psychiatrists psychiatrists; only psychiatrist absolute agreement was rating psychiatrists;
Yates, and 15 returned about 22% for a kappa of suggested that cruelty or
Serran (2002) 0.14, below acceptable torture, sexual mutilation,
levels and deviant sexual arousal
should be part of
diagnostic criteria;
questioned the adequacy
of the DSM-IV criteria
Langevin (2003) Interviews and 33 sex killers compared with Not specified Diagnosis made by evaluator 69.70% of sex killers were Sex killers showed a more
questionnaires of 33 sex 80 sexual aggressives, 23 in past sadomasochistic frequent history of sadism
killers compared with sadists, and 611 general prior to their homicides
sexual aggressive sex offenders
Berner et al. Follow up data on 1999 60 or 70 evaluated forensic Relapse rate Not specified No statistically significant Post release therapy and/or
(2003) study; methods not patients followed-up for findings; trend showing monitoring not specified;
specified an average of 6 years after patients with sexual this article also mentioned
discharge from their sadism had higher in section on criticisms
institution relapse rates
Becker et al. Legal files of 120 sexual 120 DSM-IV Mental health professionals as 8.5% sexual sadism; 2%
(2003) offenders in Arizona part of commitment sexual masochism
diagnoses
Levenson Chart review of diagnoses 450 men selected; 277 DSM-IV diagnoses Diagnoses made separately by Kappa of 0.30 for sexual The DSM is only diagnostic
(2004a, b) made on group of men included in Interrater a psychiatrist or sadism;\0.60 poor, taxonomy recognized by
evaluated by 2 evaluators reliability analysis psychologist 0.60–0.74 fair, 0.75–1.0 U.S. Courts; efforts to
Arch Sex Behav (2010) 39:325–345

for SVP commitment good 4% diagnosed with improve reliability of
sexual sadism assessment are crucial;
diagnosis difficult
because an evaluator must
infer arousal to sadistic
acts in cases where clients
do not readily admit such
arousal
Arch Sex Behav (2010) 39:325–345
Table 2 continued
Packard and Reanalysis of diagnoses 450 men selected; 277 DSM-IV diagnoses Diagnoses made by Proportion of total Kappa could be misleading;
Levenson made on group of men received psychiatric psychiatrist or psychologist agreement in diagnostic the sexual violent
(2006) evaluated by 2 evaluators diagnoses of sexual decisions was 97% for commitment process was
sadism sexual sadism highly reliable
Hill et al. (2006, Review of psychiatric court 166 men who were sexual DSM-IV diagnoses Diagnoses on the basis of 36.7% received diagnosis Authors concluded that
2007, 2008) records homicide perpetrators review of written reports of sexual sadism; 14.8% DSM-IV diagnosis of
done by 20 forensic of those with sexual sexual sadism was more
psychiatrists sadism also had sexual useful and precise than the
masochism ICD-10 sadomasochism;
however follow-up for an
estimated recidivism for
20 years at risk was not
significantly related to
diagnosis of sexual
sadism
Beauregard et al. Prospective Semi 11 sex murders of children No diagnostic criteria No diagnoses made Sex murderers of children Authors note that sadism is a
(2008) structured interview and 66 sex murders of differ from those of recurrent theme among
by psychologist and adult females adults sexual murderers and that
Computerized future studies should be
Questionnaire for Sexual undertaken to validate a
Aggressors diagnostic instrument for
sadism
Elwood et al. Data taken from archival 331 adult male sex offenders DSM-IV-TR Diagnosis made by doctoral 6.7% had sexual sadism;
(2008) database of evaluations level licensed psychologists sexual masochism not
conducted independently with 8.5 years of experience mentioned
of 331 sexual offenders
held under Wisconsin’s
sexual offender statute
McLawsen et al. E-mail survey to members 60 professionals who Items drawn from No diagnoses per se Professionals reliably Limited by small sample
(2008) of ATSA completed questionnaire several sources discriminate between size, variable experience
sadistic and nonsadistic of sample
offense behaviors
123
333
334
123
Table 3 Summary of studies with any mention of Sexual Sadism utilizing the DSM in samples from clinical or outpatient populations
Study Design Number of and source of Diagnostic criteria used Methods of Results Comments/conclusions
subjects diagnosis and data
used
Abel et al. Prospective interview of 561 Prospective interview of DSM-II and DSM-II with some Structured clinical 28 Sadism, 17 Most subjects reported sex
(1987, paraphiliacs 561 paraphiliacs in modification; deviant interest interview from masochism, crimes but had not been
1988) Memphis Tennessee was not a necessary component 1 to 5 h 126 rapists prosecuted for these
and in New York City; of arousal
none were
incarcerated; 1/3rd
referred from mental
health; 1/3rd from
legal or forensic, and
1/3rd other
Kafka and Prospective interview; 34 men in Some forensic DSM-III-R Structured In the paraphilic group, Suggested structured
Prentky paraphilia group and 26 in the interview and 4 of 34 (12%) diagnostic interviews and
(1994) paraphilia related group questionnaire diagnosed with blind interviewing
sadism and 3 (9%) techniques for future
diagnosed with studies
masochism
American Chapter in book referenced as 2,129 patients with self- Unknown; presumably answers to Not described; Sadism 2.3%
Psychiatric personal communication reported behavior at the Abel Assessment for Sexual presumably the Masochism 2.5%
Association 140 sexual treatment Interest Questionnaire Abel Assessment
(1999) clinics in North Unknown DSM criteria of Sexual Interest
America
Kafka and Prospective interview of 120 120 total; 88 men with DSM-IV Structured Sadism 4% and Suggested use of structured
Hennen consecutive males presenting for paraphlias, which interview and masochism 11% diagnostic interviews in
Arch Sex Behav (2010) 39:325–345

(2002, treatment of paraphilias or included 60 sex questionnaire future, with validated
2003) paraphilia related disorders offenders instruments
Arch Sex Behav (2010) 39:325–345 335
individuals who had nonstandard sexual interests. He proposed sample. They suggested that more recently there had evolved a
an alternative classification, Sexual Interest Disorder, to focus different distribution of Sexual Sadism versus Sexual Mas-
on sexual behavior that becomes a problem that would not ochism, with masochism being predominant in outpatient psy-
identify specific sexual interests, such as sadism, as being path- chiatric facilities and sadism prevailing in forensic settings,
ological in and of themselves. This would have two criteria: A: supporting the concept of separated diagnoses of sadism ver-
Specific fantasies, sexual urges, or behaviors that cause clini- sus masochism.
cally significant distress or impairment in social, occupational, Moser and Kleinplatz (2005) reviewed the paraphilic diag-
or other important areas of functioning; B: The sexual interest noses in all of the DSMs, and argued that paraphilias did not
is not better accounted for by another Axis I disorder, not due to meet the definition of a mental disorder and that the DSM
the effects of a general medical disorder, and is not the result of presented‘‘facts’’to substantiate various assertions in the text,
substance use, misuse, or abuse. but they found little evidence to support these assertions. They
Doren (2002) discussed many issues related to the diagnosis opined that the paraphilias section was so flawed that it should
of paraphilias in forensic settings. He made the point that in the be removed from the DSM. They suggested that an alternative
case of pedophilia one could define a numerical threshold would be to change the definition of a mental disorder or of
(such as being caught more than 2 or 3 times) for this diagnosis paraphilia or both, correct factual statements, adjust criteria for
because the penile plethysmographic (PPG) literature sug- inclusion of a diagnosis, and add safeguards to prevent the
gested that if a child molester had been caught on several misuse of the diagnoses. They indicated that other psycho-
occasions, there was a very strong likelihood (i.e., 80% or logical characteristics described individuals now diagnosed
more) that he was a pedophile (Freund & Watson, 1991). On with a paraphilia who sought psychotherapy, and said that
the other hand, attempts to develop the same sort of behavioral these concerns more accurately reflected their concerns than
definition based on PPG literature had not shown consistent their sexual interests did. They stated:
results for men who had assaulted adults. Some rapists showed
It is not their sexual interests, but the manner in which
clear sexual arousal to depictions of rape in PPG laboratories,
they are manifest that can be problematic at times and is a
and some did not, and this precluded using a numerical thresh-
more appropriate focus for therapy. The confusion of
old for defining a rape-related paraphilia in the same way that
variant sexual interests with psychopathology has led to
one could for pedophilia.
discrimination against all ‘‘paraphiliacs.’’ Individuals
Marshall and Kennedy (2003), in an extensive review of
have lost jobs, custody of their children, security clear-
Sexual Sadism in sexual offenders, reported that while most of
ances, become victims of assault, etc., at least partially
the authors in the studies they reviewed indicated that they
due to the association of their sexual behavior with psy-
used DSM or World Health Organization’s International Clas-
chopathology. (p. 107)
sification of Diseases (ICD) criteria to diagnoses their subjects,
the criteria that they specified did not comply with either of Spitzer (2005) responded to the above saying that the
these systems and each researcher chose an idiosyncratic list of concept of ‘‘medical disorder’’ could be applied to human
criteria which included some features from both DSM and ICD behavior, and doubted that anyone had been hurt by being
but also included other features not mentioned in these docu- given a diagnosis of a paraphilia. Fink (2005) maintained that it
ments. They rather pessimistically concluded: was important to retain diagnoses to differentiate between
normal and abnormal ways in which people become aroused
In conclusion then, after more than 100 years of research
and that retaining paraphilic diagnoses was important‘‘to save
and clinical observations we seem no closer to a satisfac-
some people from jail and others from themselves’’ (p. 118).
tory, agreed upon, and reliable diagnosis of sadism than
Kleinplatz and Moser (2005) said that Drs. Spitzer and Fink
was true when [von] Krafft-Ebing (1886)…first described
earlier did not dispute their analysis of the problems with the
a series of cases he called sadistic. Our review of the evi-
DSM-IV-TR criteria for paraphilias and that conservative
dence does not encourage confidence that things will
organizations had flagrantly misrepresented their statements
improve in the future, so we recommend abandoning
and intent at a symposium they had presented it at. They stated
the diagnosis. Instead, we suggest that researchers rely
that public opinion and not science were the main reasons the
on behavioral data to identify their subjects along vari-
paraphilias had been kept in the DSM.
ous dimensions of brutality. These dimensions should
Reiersøl and Skeid (2006) focused their efforts and criti-
include the degree of aggression or force, the enactment
cism on the ICD-10, concluding:
of degrading or humiliating behaviors (acts as well as
speech), and the magnitude of the victim’s injury… (pp.
The ICD diagnoses of Fetishism, Transvestic fetishism
16–17)
and Sadomasochism are outdated and not up the scien-
Berner, Berger, and Hill (2003) reviewed Sexual Sadism tific standards of the ICD manual. Their contents have
and presented follow-up data on an earlier evaluated forensic not undergone any significant changes for the last hun-
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336 Arch Sex Behav (2010) 39:325–345
dred years. They are at best completely unnecessary. At of raters, and appropriate selection of samples. The paraphi-
worst, they are stigmatizing to minority groups in soci- lias have been criticized as not being mental disorders, and,
ety. There are people who are suffering from stigma and through inclusion in the DSM enabling society to pathologize
emotional distress because of the diagnoses. (p. 260) and discriminate against people who practice alternative sex-
ual lifestyles. Those critics maintain that there is no evidence
Marshall and Hucker (2006) summarized their research on
that these lifestyles are associated with any significant degree
Sexual Sadism, which included an initial study showing that
of psychopathology.
experienced forensic psychiatrists did not accurately employ
Some experts, reviewing Sexual Sadism, have concluded
many of the important diagnostic criteria and a second dem-
that the diagnostic reliability is so poor that the use of this diag-
onstrating that ‘‘internationally-renowned’’ forensic psychia-
nosis should be abandoned in favor of dimensional approaches
trists could not reliably apply the diagnosis, and indicated that
to assessment, perhaps involving sexual arousal, or degree of
they were in the process of developing a Sexual Sadism Scale.
violence, that could be of use in treating individuals. Others
Kirsch and Becker (2007) reviewing information on psy-
have concluded that the possibility of using a threshold number
chopathy and Sexual Sadism, wrote:
of sexual assaults, for instance, to diagnose Sexual Sadism, or
Overall, the difficulties in defining and operationalizing another possible paraphilia of nonconsensual rape, is not sup-
sexual sadism, the unreliability of the diagnoses (Mar- ported by penile plethysmographic data supporting differential
shall, Kennedy, & Yates, 2002), and findings that normal arousal of rapists to violent stimuli.
males report occasional sadistic sexual fantasies Further, some have criticized the facts presented in the
(Crépault & Couture, 1980), have led some to argue for a narrative sections of the DSM concerning paraphilias, alleging
dimensional approach to defining the disorder (Marshall they are inaccurate and provide misinformation. Finally, many
& Kennedy, 2003). Given that little work has examined questions could be raised about the wording of the criteria for
the appropriateness of this approach and the available Sexual Sadism that also apply to other paraphilias (e.g., why is
research to date has used a categorical classification sys- 6 months of duration required, what does‘‘recurrent’’or‘‘intense’’
tem, this paper will consider sexual sadists to be a dis- mean, and how are these operationalized? Should ‘‘preferen-
crete group, though the reader should be aware that the tial’’ be added to the criteria for Sexual Sadism as a threshold
reliability of the diagnosis of sexual sadism is an issue for making the diagnosis, or as a qualifier, for instance?).
that warrants greater empirical attention. (p. 908)
Finally, Fedoroff (2008) in a recent review raised several
questions, without answering them, concerning the A criterion Review of Diagnostic Studies Involving Use of the DSM
for Sexual Sadism in DSM-IV-TR: ‘‘Why 6 months? What in Forensic Populations (Table 2)
does recurrent mean? What does intense mean? Is it mean-
ingful to discuss sexual urges independent of sexual fantasies? Virtually all of the published papers using DSM criteria for
Why distinguish between real and simulated acts? Appearing Sexual Sadism have been done on studies of forensic popula-
to be a fairly inclusive criteria, why is humiliation specifically tions. Many of these studies have involved sexual homicides of
identified in addition to psychological and physical suffer- one sort or another, despite the fact that these are exceedingly
ing?’’ He concluded: rare events. Chang and Heide (2009) reported, for instance, that
in 2004 sexual homicide accounted for approximately 1.1% of
This review indicates that sexual sadism, as currently
14,121 murders in the United States.
defined, is a heterogeneous phenomenon. To date,
An early study Packard and Rosner (1985) reviewed records
research has often failed to clearly define the population
of 95 defendants charged with sexual offenses evaluated in a
under study and therefore conclusions are limited. This
forensic psychiatric clinic between 1980 and 1883. DSM-III
makes generalization from research findings to specific
criteria were used and only 6.3% of individuals received a
patients problematic. Of particular concern is the pos-
diagnosis of a paraphilia, without further qualification.
sibility that correlations and outcomes from studies
Langevin, Ben-Aron, Wright, Marchese, and Handy (1988)
consisting of samples of convenience may be interpreted
reported on a small study of 13 sex killers who were inter-
as verified causal relations between unconventional sex-
viewed because they had murdered someone in conjunction
ual interests and nonconsensual sexual violence… (p.
with erotic arousal, and compared this with a sample of 13
644)
nonsexual homicide perpetrators. Seventy-five percent of the
To summarize the above, the DSM has been criticized for group who had murdered someone in conjunction with erotic
many years for its poor reliability, particularly in issues arousal had sexual sadism; 0% of the nonsexual homicide
involving its use in forensic venues. Better interrater reliability perpetrators received diagnosis of Sexual Sadism. Phallo-
has been achieved through structured instruments, education metric testing was offered in 17 cases; 9 of the subjects refused.
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Arch Sex Behav (2010) 39:325–345 337
Dietz, Hazelwood, and Warren (1990) authored an oft-cited criminated between the groups, with 75% of homicide offend-
study of 30 sexually sadistic criminals; DSM-III-R criteria ers and only 2% of incest offenders receiving diagnoses of
were not formally used, but for a case to be admitted into the Sexual Sadism. Forty percent of homicidal offenders and two
study, all three of the study authors, on the basis of a retro- percent of incest offenders received diagnoses of Pedophilia
spective chart review, had to agree that the subject had to have and Sexual Sadism. Psychiatrists made diagnoses before they
been sexually aroused in response to images of suffering or had psychological test scores of results of phallometry.
humiliation on two or more occasions spanning at least six Raymond, Coleman, Ohlerking, Christenson, and Miner
months. Documented or self-reported sexual acts were used to (1999), using a structured clinical interview for the paraphilias,
infer arousal. Seventy-seven percent of the subjects engaged in interviewed 45 males with pedophilia. They found, tabulating
sexual bondage and 100% in intentional torture of the victim. lifetime diagnoses, that two of this group had Sexual Sadism
Yarvis (1990) reported on 100 murderers he had examined and none had Sexual Masochism.
between 1980 and 1988. It appeared that 3 of 10 subjects who Berger, Berner, Bolterauer, Gutierrez, and Berger (1999)
committed a homicide/rape received a diagnosis of Sexual reported on a study that involved the assessment of sadistic
Sadism. None of the other subjects received this diagnosis. personality disorder, other personality disorders, and Sexual
Bradford, Boulet, and Pawlak (1992) reported on informa- Sadism in 70 sex offenders (27 child molesters, 33 rapists, and
tion obtained from 443 males who were consecutively admit- 10 murderers). This was a prospective study with informed
ted to the Sexual Behaviors Clinic at the Royal Ottawa Hos- consent. At least two investigators for each case made DSM-
pital, using 11 items from their Male Sexual History Ques- III-R diagnoses on the basis of separate interviews, arriving at a
tionnaire. Formal DSM criteria were not used and there was no consensus. The diagnosis of a paraphilia and the assessment of
mention of sadism or masochism. Thirty subjects admitted to sexual fantasies were assisted by a separate informal interview
rape and 56 to attempted rape. The authors suggested review- with the patient’s therapist. All available sources of informa-
ing diagnostic criteria for paraphilias and that a class of ‘‘coer- tion, such as criminal records and court reports, were used.
cive paraphilia’’be considered for the DSM. Forty-two percent of subjects had sexual sadism by the DSM-
Gratzer and Bradford (1995) compared offender and offense III-R criteria, 19% admitted to sadistic fantasies during mas-
characteristics reported on in the 30 sexually sadistic criminals turbation and only 6% admitted that they carried out sadistic
studied by Dietz et al. (1990) and compared these with 29 activites during intercourse or masturbation. In a follow-up
sexually sadistic criminals and 28 nonsadistic sexual offenders study Berner et al. (2003) following 60 of 70 patients for an
at the Royal Ottawa Hospital. Sexual sadists were more likely average of 6 years, reported there was a trend towards those
to engage in physical and psychological torture of the victim. with sexual sadism having a higher relapse rate.
Some of the offender and offense characteristics were not spe- Holt, Meloy, and Strack (1999) examined records from
cific to sexual sadism. a nonrandom sample of 41 inmates at a maximum security
Yarvis (1995) reported on a sample of 180 murderers that he prison, making a diagnosis of Sexual Sadism using threshold
had interviewed over a 13-year period using DSM-III criteria criteria from the DSM-IV and data from the subject’s prison
(used for consistency, even though DSM-III-R and DSM-IV file and a structured clinical interview. Only three individuals
were published during this period). Only individuals com- received a diagnosis of Sexual Sadism.
mitting sex crimes received a diagnosis of Sexual Sadism, with Stone (2001) reported on 98 men who had committed sex-
6.5% of rapists and 30% of sexual murderers receiving a ual homicide, whose biographies he had complied through
diagnosis of Sexual Sadism. publically available information. He reported that 18 of these
Geberth and Turco (1997) reported on a study of 232 serial 98 were reported as having the paraphilia of ‘‘sexual sadism
murderers who had violated their victims sexually (selected with orgasm.’’
from a group of 387 serial murderers) identified from the media Marshall et al. (2002) extracted archival data on 59 sexual
and the FBI’s National Center for the Analysis of Violent offenders who had been diagnosed by experienced forensic
Crime. They used a case history protocol based upon the DSM- psychiatrists in the Canadian prison system using DSM-III-R
IV criteria of antisocial personality disorder and sexual sadism, or DSM-IV criteria. Forty-one of the cases were diagnosed as
and found that 68 cases met the criteria for antisocial person- sexual sadists and 18 had been given other diagnoses. Print-
ality disorder and Sexual Sadism. These diagnoses were not outs of information from all 59 offenders were independently
separated. coded by two of the authors into 40 categories (consisting of
Firestone, Bradford, Greenberg, and Larose (1998) reviewed 18 offense features, 10 self-report categories, 7 phallometric
information collected on 48 homicidal sex offenders assessed profiles, and 5 diagnoses). They found, comparing sadists with
between 1982 and 1992, and studied these in relation to a non-sadists, that far more nonsadists were deemed to have
comparison group of incest offenders. History, psychological various personality disorders other than antisocial personality
inventories, phallometric assessments, and DSM diagnoses disorder; that sadists differed from non-sadists in only 2 of 18
were collected on each group. DSM-III diagnoses reliably dis- categories of offense characteristics (beating and torture) with
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338 Arch Sex Behav (2010) 39:325–345
nonsadists displaying higher frequencies, and that there were reliability for, among other things, the DSM-IV diagnoses
no significant differences on self-reported fantasies or acts. used to assess whether an offender had a mental abnormality.
Regarding phallometric data, nonsadists showed greater A total of 277 men were included and kappa was computed for
arousal to ‘‘nonsexual violence’’ and sadists showed greater eight DSM-IV diagnoses. Overall, kappa was found to be poor
arousal to‘‘consenting adult’’stimuli. Marshall et al. concluded to fair (kappa = 0.23–0.70) with the kappa for Sexual Sadism
that the frequency with which sexual offenders diagnosed as being only 0.30 (poor). Levenson concluded that because the
sadists displayed features identified in the literature as being DSM was the only diagnostic taxonomy recognized by U.S.
associated with sadism was lower than previously observed courts, it was critical to improve diagnosis and that diagnosis
and that the diagnosis of Sexual Sadism did not differentiate was difficult because an evaluator must infer arousal to sadistic
those deemed to be sexual sadists from those who were not. acts in cases where clients did not readily admit such arousal.
They suggested that either there were poor diagnostic practices In a separate article, the rate of Sexual Sadism was reported as
in the Correctional Services of Canada or that the criteria for being 4% (Levenson, 2004b).
Sexual Sadism were insufficient. Packard and Levenson (2006) reanalyzed their 2004 sample
Marshall, Kennedy, Yates, and Serran (2002) conducted a after concluding that there were significant limitations to using
study of 24 psychiatrists deemed to be expert in forensic diag- kappa in reliability studies. They used new statistical analyses
nosis. Each was sent 12 vignettes of men, half of whom had been measuring raw proportions of agreement, odds and risk ratios,
diagnosed in their earlier study as being sexual sadists and half and estimated conditional probabilities to examine reliability.
of whom had not received this diagnosis. However, only 15 The proportion of total agreement in diagnostic decisions for
psychiatrists completed and returned the questionnaire. The Sexual Sadism was 97%. They concluded that kappa could be
authors computed, using Cohen’s method for estimating inter- misleading when used exclusively, and that overall the civil
judge agreement, a kappa of 0.14, well below acceptable levels. commitment evaluation was a highly reliable process.
They also found that three features that there was agreement on Hill, Habermann, Berner, and Briken (2006) examined a
regarding the diagnosis of Sexual Sadism were cruelty or tor- group of court reports on 166 men who had committed a sexual
ture, sexual mutilation, and deviant sexual arousal. They sug- homicide. Psychiatric court reports were evaluated by three
gested that these features, unlike control and humiliation, were raters. Twenty forensic psychiatrists had written the reports.
not a common feature of most sexual assaults and that these Psychiatric disorders were diagnosed by the raters according to
might constitute a subclass of very dangerous sexual offenders, DSM-IV. A total of 61 (36.7%) men received a diagnosis of
and that the diagnosis of Sexual Sadism should be restricted to Sexual Sadism; no significant differences in sociodemograph-
those who met these three criteria. ic characteristics or intelligence were found. About 14 percent
Langevin (2003) compared 33 sex killers with 80 sexual of the sexually sadistic offenders were diagnosed with Sexual
aggressives who had engaged in sexual activity and killed or Masochism. A subsequent study by Hill, Habermann, Berner,
attempted to kill their victims before, during, or after the sex- and Briken (2007) reported on interrater reliability that was
ual activity. These cases were extracted from a database of assessed evaluating 20 reports by all three raters. For all Axis I
more than 2,800 cases; three comparison groups were selected, disorders, Cohen’s K ranged from 0.61 to 1.0 with a mean
including a sample of 80 nonhomocidal sexually aggressive K = 0.82, but Sexual Sadism was not specifically reported on.
men and 23 nonhomocidal sadists. Each person had been inter- Another study by Hill, Habermann, Klusmann, Berner, and
viewed and various tests were administered, including the Briken (2008) for an estimated recidivism rate at 20 years at
Clarke Sex History Questionnaire for Males and the Freund risk disclosed no relationship with Sexual Sadism.
Phallometric test of erotic preference in selected cases. Seventy Elwood, Doren, and Thornton (2008) reported on data
percent of sex killers, 30% of sexual aggressives, and 4% of all retrieved from an archival database of 331 sexual offenders
sex offenders were identified as having‘‘sadomasochism.’’ held under Wisconsin’s sexual offender statute. Diagnoses had
Becker, Stinson, Tromp, and Messer (2003) reported on a been made by doctoral level licensed psychologists, using the
review of the legal files of 120 sexual offenders, the entire DSM-IV criteria. A total of 8.5% had Sexual Sadism.
population up to the time of the study of men who were peti- McLawsen, Jackson, Vannoy, Gagliardi, and Scalora (2008)
tioned for civil commitment in Arizona. Of these offenders, sent an anonymous and confidential survey through the Asso-
8.5% received diagnoses of Sexual Sadism and 2% Sexual ciation for the Treatment of Sexual Abusers (ATSA) and the
Masochism. American Psychology-Law Society (AP-LS) e-mail list to pro-
Levenson (2004a) reported on a study that consisted of a fessionals who made diagnoses of Sexual Sadism. Sixty par-
review of diagnostic data drawn from a sample of 450 male ticipants completed the survey. Participants had made an aver-
convicted sex offenders in Florida prisons who had received an age of 2.54 diagnoses of Sexual Sadism. Sixty-two statements
independent in-person evaluation by at least two psychologists were included in the survey, drawn from four conceptualiza-
or psychiatrists for SVP civil commitment during the 2000 and tions of Sexual Sadism, with items culled from an extensive
2001. The purpose of the study was to calculate the interrater literature review. Participants were asked to rate each statement
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Arch Sex Behav (2010) 39:325–345 339
on a 7-point Likert-type scale from ‘‘not at all essential’’ to population of 561 men seeking voluntary evaluation and
‘‘absolutely essential’’for making a diagnosis of Sexual Sadism. treatment for possible paraphilias in Memphis, Tennessee or
The items were divided into two mutually exclusive categories: in New York City. In the Memphis sample, all categories of
Sexual Sadism (39 items) and a general sexual offending cat- paraphilias were evaluated; in the New York sample, mostly
egory (23 items). Overall, ratings of the two categories differed subjects with a diagnosis of rape or child molestation were
significantly, indicating that participants were able to differ- seen. DSM-II and DSM-III criteria were used, with all subjects
entiate Sexual Sadism from general sexual offending. Behav- reporting recurrent, repetitive urges to carry out deviant sexual
iors that were common to three of the four conceptualizations behaviors. Subjects were not included in the research solely
were ‘‘slapped or punched victim during the sexual act; cut, because they had committed the paraphilic behavior. One-
stabbed, strangled, bit, or beat victim during sexual act; and, third of this sample was referred from legal or forensic sources,
physical restraints used during sexual act’’(p. 294). one-third from mental health sources, and one-third from other
Beauregard, Stone, Proulx, and Michaud (2008) reported sources. A total of 28 men were diagnosed with sadism, 17
on a small study in which 11 sexual murderers of children with masochism, and 126 as rapists.
and 66 sexual murderers of adult women were interviewed. Kafka and Prentky (1994) collected data prospectively on
Although no diagnostic instruments or criteria were described, 63 consecutively evaluated outpatient males. Three men were
it was concluded that because sadism was a recurrent theme excluded. Thirty-four were seeking treatment for paraphilic
among sexual murderers that future studies should be under- disorders and 26 for paraphilia related disorders. A question-
taken to validate a diagnostic instrument of sadism. naire was used along with a structured interview to establish a
So, to summarize the above, some 27 studies have utilized diagnosis, which represented a lifetime diagnosis. It was not
or referred to DSM criteria for the evaluation of subjects in clear which paraphilia was the focus for treatment. Twelve
forensic populations. Most studies were not prospective, i.e., percent of the paraphilic group was diagnosed with Sexual
they relied on data that had already been obtained by inter- Sadism and 9% with Sexual Masochism. Kafka and Prentky
viewers. Some relied not on direct interviews but on criminal recommended that future studies should utilize structured
records or information from the media. In those studies that diagnostic interviews and blind interviewing techniques
relied on clinical information, almost none of the primary In the volume Dangerous Sex Offenders (American Psy-
interviewers had utilized structured diagnostic instruments chiatric Association, 1999), there were some data in the form of
specifically geared towards making diagnoses of the paraph- a personal communication from Dr. Gene Abel on a sample of
ilias or, for that matter, of any of the psychiatric disorders. This 2,129 patients evaluated at 140 sexual treatment clinics in North
is important in that it is conceivable, given the association of America, who presumably answered questions on the Abel
Sexual Sadism with Sexual Masochism, for instance, that one Assessment of Sexual Interest, although this was not explicitly
might find a substantial occurrence of Sexual Masochism in stated. Of this sample, 2.3% reported they had engaged in
individuals with Sexual Sadism. Yet, the study design and data sadism and 2.5% in masochism, but the methods and questions
collection did not allow for this data to be generated and we do used to obtain this information were not described.
not, in fact, know, if questions pertaining to sexual masochism Kafka and Hennen (2002, 2003) reported on a population of
or the other paraphilias were even regularly included in inter- 120 consecutively evaluated outpatient males with paraphilias
views or assessments. (N = 88, including 60 sex offenders), and paraphilia-related
Few studies have examined interrater reliability. Those disorders (N = 32). Structured interviews and DSM-IV crite-
studies that have are not entirely comparable. Some have ria were used to make lifetime diagnoses. Eleven percent of
found good interrater reliability and some have found poor the paraphilic sample had Sexual Masochism and 5% Sexual
reliability. It is not apparent, however, that this poor interrater Sadism. Kafka and Hennen noted that there were no rating
reliability is a consequence of ambiguous or poor criteria for instruments with documented reliability and validity to diag-
Sexual Sadism. It could as well be that lack knowledge about nose both paraphilias and paraphilia related disorders. The
diagnostic criteria, lack of training in those conducting the index paraphilia for which treatment was sought was not spec-
primary interviews, or failure to use structured instruments ified.
could account for poor interrater reliability. The above four studies are the only studies I have found
which apply DSM criteria for Sexual Sadism to populations
that are not exclusively forensic, and each of these studies has
Summary of Studies with any Mention of Sexual Sadism a substantial component of forensic cases. This implies that
Utilizing the DSM in Samples Drawn from Clinical researchers are not using criteria from the DSM to conduct
or Not Clearly Forensic Populations (Table 3) research on non-forensic community populations or popula-
tions seeking treatment, and/or that individuals with Sexual
Abel et al. (1987) and Abel, Becker, Cunningham-Rather, Sadism are not presenting in any substantial numbers in a non-
Mittelman, and Rouleau (1988) reported on an outpatient forensic way for treatment.
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340 Arch Sex Behav (2010) 39:325–345
Other Issues might anticipate that therapy for those practicing S & M may
involve issues other than their S & M or involve‘‘normalizing’’
Research on Sadomasochism in the Community (i.e., making acceptable) their sexual fantasies or behavior
(Kleinplatz & Moser, 2004; Nichols, 2006). With forensic
Moser and Levitt (1987) reported that general population sur- populations, the focus would be on controlling or suppressing
veys had not established the proportion that identified as S/M sadistic arousal and behavior (Krueger & Kaplan, 2002).
and noted that it was not clear if any specific behaviors could be These observations suggest that there is a substantial occur-
classified as S/M specifically. Paraphilic disorders have, to rence of sadomasochistic behavior in the community, that some
date, not been included in any of the broad epidemiological research is being done on it, and that some people seek out
surveys of mental disorders (Kessler et al., 2005). Yet S & M consultation from mental health professionals for this. It would
behavior would appear to be fairly common. Kinsey, Pomeroy, appear, however, that the DSM is not being used for research
Martin, and Gebhard (1953, p. 678) reported that 26% of purposes for this population and perhaps not for clinical pur-
females and 26% of males reported a definite and/or frequent poses either.
erotic response to being bitten. In a survey of sexual behavior
in the United States involving 2,026 respondents in 26 cities, Relationship and Cultural Context
Hunt (1974) found that 4.8% of males and 2.1% of females
reported ever having obtained sexual pleasure from inflicting Mitchell and Graham (2008) raised the issue that relationship
pain, and 2.5% of males and 4.6% of females from receiving influences are not considered in the diagnosis of sexual dis-
pain. Females appear to have a significant presence among S & orders and Tiefer (2004) and Tiefer, Brick, and Kaplan (2003)
M practitioners. Breslow, Evans, and Langley (1985, 1995) noted that both relationship and cultural context are important
reported on a study in which questionnaires were placed in two in assessing and treating sexual disorders. It is notable that the
publications that catered to sadomasochists; of 182 individuals paraphilias, presumably because some of these behaviors are
who responded, 130 were males and 52 females, indicating a illegal and nonconsensual, do not include any relationship
significant female presence in the subculture. Finally, studies specifiers. Given that sadomasochism is one of the paraphilias
from the S & M population could have much to contribute to that could occur in the context of a relationship (along with
an understanding of sexual sadism. For instance, Cross and transvestic fetishism, and perhaps some of the other unnamed
Matheson (2006) suggested that power, and not the giving and paraphilias), it might make sense to consider including this
receiving of pain, was at the core of S & M. Again, it is dimension in the criteria.
important, however, to distinguish individuals practicing S &
M as part of consensual sexual activity from individuals who Misuse of DSM in Child Custody Proceedings
have been arrested for such activity and are in the forensic and Discrimination
system.
There also is little information on how many individuals Klein and Moser (2006) described the case of the misuse by
seek help because of their sadomasochistic orientation. Wein- forensic professionals of the DSM criteria in a child custody
berg (2006) concluded his review of the social and psycho- suit, suggesting that these not infrequent cases should be an
logical literature by stating that ‘‘sociological and social psy- impetus to the editors of the DSM to reevaluate its classi-
chological studies see SM practitioners as emotionally and fication of atypical sexual behavior as pathological and to
psychologically well balanced, generally comfortable with their strengthen its warnings against misuse. Wright (2006) pre-
sexual orientation, and socially well adjusted’’(p. 37). In a study sented information on violence and discrimination against
of 245 manifestly sadomasochistic West German men, Spen- SM-identified individuals; of 1017 SM individuals surveyed,
gler (1977, 1983) reported that 20% rejected their sadomas- 36% had suffered some sort of violence or harassment because
ochistic orientation, 70% accepted it, and 9% ‘‘didn’t know.’’ of their SM practices, and 30% had been victims of job dis-
Ninety percent had never visited a doctor, psychiatrist, or crimination.
psychologist because of their sadomasochistic deviation, but
10% reported doing this at least once. Another study by Moser
and Levitt (1987) reported on the results of a questionnaire Recommendations and Discussion
given to 178 men self-defined as S & M. Most respondents
were satisfied with the S & M part of their sexuality, but 6% Should Sexual Sadism Be Retained in the DSM?
expressed distress concerning their behavior and 16% had
sought help from a therapist for their S & M desires. Yes. The above summaries make clear that Sexual Sadism is a
Finally, the focus and nature of therapy for those from the prominent diagnosis and entity in forensic populations. It,
community who might present to practitioners is different along with other psychiatric diagnoses, presents a clear target
from the focus of those who are in forensic situations. One of treatment. Treatment of psychiatric conditions is a corner-
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Arch Sex Behav (2010) 39:325–345 341
stone in addressing and reducing risk in forensic populations. the U.S. Government and, with appropriate protections
In some places in the narrative section, there are descriptions of related to self-incrimination, identity protection, and sensi-
sadistic behavior or other assertions without the caution that tively designed survey questions, I see no reason why
much of the information is derived from forensic populations structured instruments could not be developed for the
and may not apply to community populations. The narrative paraphilias in future government or academically con-
section of the DSM should be rewritten to reflect this. Addi- ducted surveys.
tionally, caveats circumscribing the application of the DSM in 4. What about dimensional ascertainment for Sexual Sadism
forensic matters, particularly as regards Sexual Sadism and and poor interrater reliability? Marshall and Kennedy
Sexual Masochism, should be reviewed and strengthened. (2003) recommended abandoning the present diagnostic
criteria and shifting to a dimensional approach to defining
sadism. I am in favor of exploring dimensional approaches,
Should There Be Any Changes in the Diagnostic Criteria? but not of abandoning the diagnostic criteria.
It should be noted that this summary reflects my original
Yes. The current criteria are listed in Appendix 1. I would
literature review. Subsequently, interactions with other mem-
recommend the following changes (see also Appendix 1):
bers of the workgroup and advisors have resulted in modifi-
1. The phrase ‘‘or behaviors’’ be deleted from criterion A. cation of these initial suggestions.
This would address the concerns raised by the editors of
DSM-IV-TR (First & Frances, 2008) that inclusion of the Acknowledgments This article was prepared with the assistance of
Dr. Meg Kaplan. The author is a member of the DSM-V Workgroup on
term‘‘or behavior’’ allowed for the inappropriate conclu-
Sexual and Gender Identity Disorders (Chair, Kenneth J. Zucker, Ph.D.).
sion that an individual qualified for a mental illness solely I wish to acknowledge the valuable input I received from members of my
on the basis of repeated criminal acts. Paraphilias subworkgroup (Ray Blanchard, Marty Kafka, and Niklas
2. The phrase‘‘real, not simulated’’should be deleted from the Långström) and Kenneth J. Zucker. Reprinted with permission from the
Diagnostic and Statistical Manual of Mental Disorders V Workgroup
A Criterion. I cannot see that this adds any real distinction.
Reports (Copyright 2009), American Psychiatric Association.
This appears to have been added in the second criterion (2)
in DSM-III for the diagnosis of Sexual Sadism, but there is
no information as to the reason this was added.
3. Should the criteria be expanded to include cruelty or tor- Appendix 1: Sexual Sadism
ture, sexual mutilation, and deviant sexual arousal as
Marshall et al. (2002) have suggested? Should the criteria Diagnostic Criteria for Sexual Sadism from DSM-I
be modified to include behaviors that were common to to DSM-IV-TR
three of the four conceptualizations identified by McLaw-
sen et al. (2008), and summarized by the following phrases: DSM-I (American Psychiatric Association, 1952)
‘‘slapped or punched victim during the sexual act; cut,
stabbed, strangled, bit, or beat victim during sexual act; The only mention of sexual sadism occurs under the catego-
and, physical restraints used during sexual act?’’ rization of Sociopathic Personality Disturbance (000-x60):
No. I think that each of these studies does not present Sexual Deviation. This diagnosis is reserved for deviant
enough evidence to expand on or alter the definitional sexuality which is not symptomatic of more extensive
items in Criteria A. I would strongly recommend the syndromes, such as schizophrenic and obsessional reac-
development and use of structured diagnostic instruments tions. The term includes most of the cases formerly
for the validation of diagnostic criteria and exploration classed as ‘‘psychopathic personality with pathologic
and validation of other possible items that may be relevant sexuality.’’ The diagnosis will specify the type of the
to Sexual Sadism in the clinical and forensic areas. An pathologic behavior, such as homosexuality, transves-
abundant literature supports the utility of such structured tism, pedophilia, fetishism and sexual sadism (including
instruments in increasing interrater reliability in other rape, sexual assault, mutilation). (pp. 38–39)
areas of psychiatric diagnosis (Kranzler et al., 1995; Miller,
Dasher, Collins, Griffiths, & Brown, 2001; Shear et al.,
DSM-II (American Psychiatric Association, 1968)
2000; Steiner, Tebes, Sledge, & Walker, 1995) and I would
suggest creation of structured diagnostic instruments for
Sadism is classified as one of the Sexual Deviations (302.6):
the paraphilias and questionnaires that could yield survey
more information about other features or behaviors asso- Sexual Deviations. This category is for individuals
ciated with this diagnosis. Further, sexual surveys are whose sexual interests are directed primarily towards
done in an annual way on all sorts of sexual behavior by objects other than people of the opposite sex, toward
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342 Arch Sex Behav (2010) 39:325–345
sexual acts not usually associated with coitus, or toward DSM-IV-TR (American Psychiatric Association, 2000)
coitus performed under bizarre circumstances as in nec-
rophilia, pedophilia, sexual sadism, and fetishism. Even The change in the B. criterion from DSM-IV to DSM-IV-TR
though many find their practices distasteful, they remain represents one of the few changes in criteria from DSM-IV to
unable to substitute normal sexual behavior for them. DSM-IV-TR. This change was made to all of the paraphi-
This diagnosis is not appropriate for individuals who lias which involved a victim, to remove any ambiguity about
perform deviant sexual acts because normal sexual whether acting out sexual urges with others was sufficient for a
objects are not available to them. (p. 44) diagnosis; some had argued that an individual with a paraphilia
who was not distressed about his or her behavior could not be
diagnosed with a paraphilia, and this new wording allowed for
DSM-III (American Psychiatric Association, 1980)
a diagnosis to be made in such a circumstance.
The diagnostic criteria for sexual sadism were revised from
Sexual sadism is classified as one of the paraphilias, with one
DSM-IV:
of the following criteria necessary for the diagnosis:
A. Over a period of at least 6 months, recurrent, intense
(1) on a nonconsenting partner, the individual has repeatedly
sexually arousing fantasies, sexual urges, or behaviors
intentionally inflicted psychological or physical suffer-
involving acts (real, not simulated) in which the psycho-
ing in order to produce sexual excitement
logical or physical suffering (including humiliation) of
(2) with a consenting partner, the repeatedly preferred or
the victim is sexually exciting to the person.
exclusive mode of achieving sexual excitement com-
B. The person has acted on these sexual urges with a non-
bines humiliation with simulated or mildly injurious
consenting person, or the sexual urges or fantasies cause
bodily suffering
marked distress or interpersonal difficulty.
(3) on a consenting partner, bodily injury that is extensive,
permanent, or possibly mortal is inflicted in order to
achieve sexual excitement. Suggested Criteria Following Literature Review for DSM-V
These criteria reflect my initial suggestions. Subsequently,

DSM-III-R (American Psychiatric Association, 1987) interactions with other members of the workgroup and advis-
ors have resulted in a modification of these initial suggestions.
The diagnostic criteria for sexual sadism were revised as
follows: A. Over a period of at least 6 months, recurrent, intense
sexually arousing fantasies or sexual urges involving acts
A. Over a period of at least six months, recurrent intense in which the psychological or physical suffering (includ-
sexual urges and sexually arousing fantasies involving ing humiliation) of the victim is sexually exciting to the
acts (real, not simulated) in which the psychological or person.
physical suffering (including humiliation) of the victim is B. The person has acted on these sexual urges with a non-
sexually exciting to the person. consenting person, or the sexual urges or fantasies cause
B. The person has acted on these urges, or is markedly dis- marked distress or interpersonal difficulty.
tressed by them.
Appendix 2: Sexual Sadism

DSM-IV (American Psychiatric Association, 1994)
The ICD-9 and ICD-10 Criteria for Sexual Sadism and
The diagnostic criteria for sexual sadism were:
Sexual Masochism and the ICD-10 Diagnostic Criteria
A. Over a period of at least 6 months, recurrent, intense for Research for Sadomasochism
sexually arousing fantasies, sexual urges, or behaviors
involving acts (real, not simulated) in which the psycho- The ICD-9-CM Diagnostic Criteria for Sadism and Masoch-
logical or physical suffering (including humiliation) of ism (World Health Organization, 1989) (p. 229) are:
the victim is sexually exciting to the person.
302.8 Other specified psychosexual disorders
B. The fantasies, sexual urges, or behaviors cause clinically
significant distress or impairment in social, occupational, 302.83 Sexual masochism
or other important areas of functioning. 302.84 Sexual sadism
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Arch Sex Behav (2010) 39:325–345 343
The ICD-10 International Statistical Classification of Dis- American Psychiatric Association. (1968). Diagnostic and statistical
eases and Related Health Problems, Tenth Revision (World manual of mental disorders (2nd ed.). Washington, DC: Author.
Health Organization, 1992) (p. 367) criteria are: manual of mental disorders (3rd ed.). Washington, DC: Author.
Disorders of sexual preference
manual of mental disorders (3rd ed., revised). Washington, DC:
Includes: paraphilias Author.
F65.5 Sadomasochism American Psychiatric Association. (1994). Diagnostic and statistical
A preference for sexual activity which involves the inflic- American Psychiatric Association. (1999). Dangerous sex offenders.
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Arch Sex Behav (2010) 39:346–356
DOI 10.1007/s10508-010-9613-4
ORIGINAL PAPER
The DSM Diagnostic Criteria for Sexual Masochism

Richard B. Krueger
Published online: 10 March 2010

Abstract I reviewed the empirical literature for 1900–2008 DSM, the existent studies that have offered critiques relevant to
on the paraphilia of Sexual Masochism for the Sexual and the diagnosis of Sexual Masochism, and the few studies that
Gender Identity Disorders Work Group for the forthcoming fifth have used criteria from the DSM in both forensic and not clearly
edition of the Diagnostic and Statistical Manual of Mental Dis- forensic populations. It will review other information obtained
orders. The results of this review were tabulated into a gen- from community samples and then offer recommendations for
eral summary of the criticisms relevant to the DSM diagnosis of the diagnostic criteria for DSM-V.
Sexual Masochism, the assessment of Sexual Masochism uti- Further, for ease of reference, several tables have been devel-
lizing the DSM in samples drawn from forensic populations, oped. Table 1 contains criticisms relevant to Sexual Masochism,
and the assessment of Sexual Masochism using the DSM in non- Table 2 lists studies that have utilized DSM-criteria on Sexual
forensic populations. I concluded that the diagnosis of Sexual Masochism in exclusively forensic populations, and Table 3
Masochism should be retained, that minimal modifications of contains studies that have been done using the DSM on mixed
the wording of this diagnosis were warranted, and that there was (consisting of both forensic and non-forensic) populations.
a need for the development of dimensional and structured diag- Finally, an appendix listing all of the previous DSM criteria sets
nostic instruments. It should be noted that this summary reflects for Sexual Masochism (Appendix 1), along with ICD-9 (World
my original literature review. Subsequently, interactions with other Health Organization, 1989) and ICD-10 criteria (World Health
members of the workgroup and advisors have resulted in modifi- Organization, 1992), and ICD-10 research criteria (World
cation of these initial suggestions. Health Organization, 1993) for sadomasochism are appended
(Appendix 2).
Keywords Paraphilia Sexual sadism
Sexual masochism Hypoxyphilia DSM-V
Method
Introduction Consisted of a literature search by the librarian of the New York

State Psychiatric Institute using the search terms of‘‘sexual mas-
In contrast to the literature on Sexual Sadism (see Krueger, ochism,’’ ‘‘sexual sadism,’’ ‘‘sadomasochism,’’ ‘‘domination,’’
2009), there are many fewer studies that have utilized the DSM ‘‘bondage,’’‘‘BDSM,’’‘‘perversion,’’‘‘paraphilia,’’‘‘sexual homi-
in the assessment of Sexual Masochism. This article will review cide,’’‘‘sexual murder,’’‘‘lust murder,’’and‘‘sex killer’’of PubMed
the evolution of the terminology of Sexual Masochism in the from 1966 through December 15, 2008, and of Psych Info from
1900 through December 15, 2008. Additionally, all of the prior
Diagnostic and Statistical Manuals were consulted as well as
ICD-9 and ICD-10. Articles were culled and attention was
focused on articles using the DSM to make diagnoses of Sexual
R. B. Krueger (&)
Masochism or offering critiques of the diagnostic criteria for
Sexual Behavior Clinic, New York State Psychiatric Institute,
1051 Riverside Drive, Unit 45, New York, NY 10032, USA Sexual Masochism or the paraphilias. Discussion of this literature
e-mail: [email protected] and the diagnostic criteria was engaged in with colleagues.
123
Table 1 Summary of criticisms relevant to the DSM diagnosis of sexual masochism
Tallent (1977) Peer reviewed article Paraphilias Paraphilias, like homosexuality, should be removed from the DSM; they represent value judgments
only and not scientifically established criteria
Silverstein (1984) Peer reviewed article Paraphilias Paraphilias, like homosexuality, should be removed from the DSM; they represent value judgments
only and not scientifically established criteria
Suppe (1984) Peer reviewed article DSM-III and the paraphilias Sexual deviation is not a diagnostic entity. Paraphilias should be removed from DSM. Burden of proof
that these are personally or socially harmful rests with advocates of DSM: deletion may not change
social attitudes
Arch Sex Behav (2010) 39:346–356
Grove et al. (1981) Peer reviewed article All DSM diagnoses Diagnostic reliability had improved in psychiatry because of carefully constructed interview
schedules and lists of diagnostic criteria, along with rigorous training of raters; much work
remained undone
Kirk and Kutchins (1994) Peer reviewed article All DSM diagnoses Reanalyzed data gathered in original DSM-III field trials and suggested that earlier claims of Interrater
reliability were overstated
Gert (1992) Peer reviewed article DSM-III-R; all paraphilias Liked definition of mental disorder; would change definition of paraphilia, specifically transvestic
fetishism, to be consistent with definition of mental disorder
Schmidt (1995), Schmidt Book chapter Broad discussion of all of DSM Summarized that the literature reviews completed for DSM-IV revealed a paucity of data supporting
et al. (1998) sexual disorders including the scientific conceptual underpinning of current diagnostic terminology regarding sexual
paraphilias psychopathology
Campbell (1999) Peer reviewed article All DSM diagnoses Evidentiary reliability of DSM-IV consistently flounders because of lack of interrater reliability data.
Campbell (2004) Book Later books suggested extended this to sex offender assessment
Campbell (2007) Book
McConaghy (1999) Peer reviewed article Broad review of sexology; all of Suggested that the DSM-IV stated that the severity of sadistic acts increased over time; that while this
DSM may apply to serial or sadistic murderers, who were extremely rare, the lack of presentation for
treatment of subjects who practiced S & M suggested that this was more benign. Said that this
statement regarding progression was made towards sadism generally and was misleading.
Suggested that, in view of the lack of a relationship of S & M with psychiatric pathology, as was the
case with homosexuality, it would be reasonable that sadomasochism should also not be classified
as a disorder
Moser (2001) Book chapter All of DSM paraphilias Argues DSM ‘‘pathologizes’’ individuals who have nonstandard sexual interests despite a lack of
research establishing difference in functioning; presents broad review and criticism; suggests the
classification of ‘‘Sexual Interest Disorder’’
Berner et al. (2003) Peer reviewed article ICD-10 and DSM-IV Current studies on differently selected clinical samples reveal changed distribution with masochism
prevailing in outpatient facilities and sadism in forensic settings; no survey data were presented to
support this impression
Moser and Kleinplatz (2005) Peer reviewed article All, with focus on DSM-IV-TR Asserted there were many factual mistakes in the text; that paraphilias were not mental disorders; that
inclusion of paraphilias in the DSM facilitated discrimination and harm to people with variant
sexual interests; and that, for consenting adults, it was not their sexual interests but the manner in
which they were manifest that was a problem and more appropriate focus for therapy
Spitzer (2005) Peer reviewed article All, with focus on DSM-IV-TR Contended that‘‘medical disorder’’could be applied to human behavior; said that Moser and Hill had
not presented a single case (child or adult) of someone who had been harmed by being given a
diagnosis of a paraphilia
347
123
348 Arch Sex Behav (2010) 39:346–356
statements and intent of the symposium it was presented at and the APA. Stated that public opinion
The ICD diagnoses of Fetishism, Transvestic Fetishism, and Sadomasochism are outdated and not up
Expressed that there must be some way of differentiating between the normal and abnormal ways in
Maintained that Spitzer and Fink did not dispute their analysis of the problems with the DSM-IV-TR
Results
which people get aroused, excited, and fulfilled. Thought it was important to retain paraphilic
criteria for paraphilias and that conservative organizations flagrantly misrepresented their
Summary of Evolution of Diagnostic Criteria for Sexual
Masochism in the DSM
diagnosis ‘‘in order to save some people from jail and others from themselves’’
to the scientific standards of the ICD manual. They stigmatize minority groups
Masochism was not mentioned in DSM-I (American Psychi-
atric Association, 1952). It was added to DSM-II for use in the
and not science were the main reason to keep the paraphilias in DSM United States only (American Psychiatric Association, 1968)
(Appendix 1).
It was continued in DSM-III (American Psychiatric Asso-
ciation, 1980), where this diagnosis was made with either of the
items: ‘‘(1) A preferred or exclusive mode of producing sex-
ual excitement is to be humiliated, bound, beaten, or otherwise
made to suffer, or (2) The individual has intentionally partici-
pated in an activity in which he or she was physically harmed or
his or her life was threatened’’(p. 274). Thus, an individual could
have been diagnosed with this disorder only for participating in
such activity with a consensual partner, if this was preferred or
exclusive.
DSM-III-R (American Psychiatric Association, 1987) changed
to require two criteria:‘‘A. Over a period of at least six months,
recurrent, intense sexual urges and sexually arousing fantasies

involving the act (real, not simulated) of being humiliated,
beaten, bound, or otherwise made to suffer.’’And‘‘B. The per-
son has acted on these urges, or is markedly distressed by them.’’
Here again, the occurrence of such urges or fantasies in an indi-
vidual who was practicing S & M with a consensual partner
was in itself considered pathological, providing substance to the
claims by S & M practitioners that their particular behavior had
All with focus on DSM-IV-TR
All with focus on DSM-IV-TR
been selected out as being pathological per se.

Diagnostic criteria criticized
In DSM-IV (American Psychiatric Association, 1994), the A

criterion was continued, substantially unchanged: ‘‘A. Over a
period of at least 6 months, recurrent, intense sexually arousing
fantasies, sexual urges, or behaviors involving the act (real, not
simulated) of being humiliated, beaten, bound, or otherwise
made to suffer.’’ And the B criterion, as with the other paraph-
ICD-10
ilias, was modified to incorporate elements of subjective dis-

tress or dysfunction:‘‘B. The fantasies, sexual urges, or behaviors
cause clinically significant distress or impairment in social, occu-
pational, or other important areas of functioning.’’Finally, DSM-

IV-TR (American Psychiatric Association, 2000) made no
changes in the criteria.
Source
Review of Criticisms Relevant to Sexual Masochism

Kleinplatz and Moser (2005)
Many criticisms relevant to Sexual Sadism are also relevant to

Reiersøl and Skeid (2006)
Sexual Masochism, and are contained in Table 1 and will not be

repeated here (see Krueger, 2009). Generally, these indicate,
Table 1 continued
among many concerns, that the paraphilias, or sadomasochism,

should not be included in the DSM because they are not men-
Fink (2005)
tal disorders, they are unscientific, they are unnecessary, and

Author
to do so pathologizes groups who engage in alternative sexual

practices.
123
Arch Sex Behav (2010) 39:346–356 349
Conclude that DSM-IV diagnosis of
recidivism for 20 years at risk was

Indeed, Baumeister and Butler (1997) entitled their chapter
sexual sadism was more useful

interview for sexual diagnoses
examined from the structured
in the edited volume Sexual Deviance as ‘‘Sexual Masochism:
and precise than the ICD-10
diagnosis of sexual sadism

follow-up for an estimated
Diagnosis of masochism was
sadomasochism; however,
not significantly related to

Deviance without Pathology,’’emphasizing that it was not path-
ological. In a recent chapter on Sexual Masochism, Hucker
(2008) reviewed the literature. He wrote, addressing the call to
which was used

remove the paraphilias from the DSM:
On the other hand, the fact that a minority of sadomas-
ochists do present with serious injuries or die during their
activities (Agnew, 1986; Hucker, 1985) should make us
consider seriously whether removing these behaviors from
the domain of mental disorders is wise at the present time,
sexual sadism also had

8.5% sexual sadism; 2%
sadism; 0 had sexual
14.8% of those with

diagnosis of sexual
especially as there is much room for more research on
sexual masochism
sexual masochism
sexual masochism
sadism; 5.4% had
2 of 45 had sexual
the topic. Kurt Freund (Freund, 1976) applied the term

36.7% received
‘‘dangerous’’ to the more extreme forms of sadism and

masochism
masochism, and it would seem prudent at this stage in our

Results
knowledge to continue to refer to these more extreme

Table 2 Summary of studies involving assessment of sexual masochism utilizing the DSM in samples drawn from forensic populations
cases by such a term, thereby distinguishing them from the

more benign manifestations (‘‘mild’’masochism or erotic
Diagnoses on the basis of review
of written reports done by 20
submissiveness) of what may well be a continuum of

Methods of diagnosis and data
Mental health professionals as

using structured diagnostic
Interview; prospective study
behaviors that merges with ‘‘normal’’ sexual expression.

(pp. 260–261)
forensic psychiatrists
part of commitment
Review of Diagnostic Studies in Forensic Populations

instruments
diagnoses
Only three studies mention the diagnosis of Sexual Masochism

used
based on the DSM in studies of forensic populations and these

do not indicate a high occurrence of this diagnosis. In a study of
45 males with pedophilia using an unvalidated structured clin-
criteria used
ical interview for the sexual disorders, Raymond, Coleman,

Diagnostic
DSM-IV
DSM-IV
DSM-IV
Ohlerking, Christenson, and Miner (1999) found that no sub-

jects met criteria for sexual masochism, despite the discovery of
numerous other paraphilias, in addition to pedophilia.
Becker, Stinson, Tromp, and Messer (2003) reported on a
source of subjects
Number of and
perpetrators
were sexual
review of the legal files of 120 sexual offenders who were peti-
45 males with
166 men who

pedophilia
homicide
tioned for civil commitment in Arizona. A total of 8.5% received

a diagnosis of sexual sadism and only 2% sexual masochism.
120
Hill, Habermann, Berner, and Briken (2006) examined court

reports on 166 men who had committed a sexual homicide in
with pedophilia using,
Germany. Psychiatric disorders were diagnosed by the raters

Legal files of 120 sexual
Interview of volunteers
offenders in Arizona
among other things,
Review of psychiatric
according to DSM-IV. Sixty-one men (36.7%) received a diag-

nosis of Sexual Sadism, 5.4%. received a diagnosis of Sexual
court records
sexual SCID
Masochism, and 14.8% of those with Sexual Sadism also had

Sexual Masochism. Structured diagnostic instruments were used
Design
to make diagnoses of personality disorders, but not for the para-

philic disorders.
To summarize, only three studies have been conducted on
forensic populations that mention Sexual Masochism diagnosed
Becker et al. (2003)
by the DSM, compared with a substantial volume of studies

Hill et al. (2006,
Raymond et al.
2007, 2008)
examining for Sexual Sadism. One of these studies reported no

Sexual Sadism in a group of 45 males with pedophilia, one an
(1999)
Study
occurrence of 2% out of 120 civilly committed sexual offenders,

and one 5.4% in a group of 166 men who had committed a sexual
123
350
123
Table 3 Summary of studies with any mention of sexual masochism utilizing the DSM in samples that are not entirely forensic
Study Design Number of and source of Diagnostic criteria used Methods of diagnosis Results Comments/conclusions
subjects and data used
Abel et al. (1987, Prospective interview of 561 Prospective review of 561 DSM-II and DSM-II with Structured clinical 28 sadism, 17 Most subjects reported sex
1988) paraphiliacs paraphiliacs in some modification; interview from 1 masochism, crimes but had not been
Memphis Tennessee deviant interest was not a to 5 h 126 rapists prosecuted for these
and in New York City; necessary component of
none were incarcerated; arousal
one-third referred from
mental health; one-third
from legal or forensic,
and one-third other
Kafka and Prentky Prospective interview; 34 Some forensic DSM-III-R Structured interview In the paraphilic group, 4 Suggested structured
(1994) men in paraphilia group and questionnaire (12%) of 34 diagnosed diagnostic interviews and
and 26 in the paraphilia with sadism and 3 blind interviewing
related group (9%) diagnosed with techniques for future
masochism studies
American Chapter in book referenced 2,129 patients with self- Unknown; presumably Not described; Sadism (2.3%) and
Psychiatric as personal reported behavior at 140 answers to the Abel presumably the masochism (2.5%)
Association communication sexual treatment clinics Assessment For Sexual Abel Assessment
(1999) in North America Interest Questionnaire of Sexual Interest
Unknown DSM criteria
Kafka and Hennen Prospective interview of 120 120 total; 88 men with DSM-IV Structured interview Sadism (4%) and Suggested use of structured
(2002, 2003) consecutive males paraphlias, which and questionnaire masochism (11%) diagnostic interviews in
presenting for treatment included 60 sex future with validated
of paraphilias or offenders instruments
paraphilia related
disorders
Arch Sex Behav (2010) 39:346–356
Arch Sex Behav (2010) 39:346–356 351
homicide. In this group, 14.8% of men who had Sexual Sadism documented reliability and validity available to diagnose both
also had Sexual Masochism. It is also not clear to what extent paraphilias and paraphilia-related disorders. The index para-
sexual masochism was contributory to any criminal behavior in philia for which treatment was sought was not specified.
these studies. Only one of these studies used structured diagnos- The above four studies were the only ones I have found which
tic instruments to assess for paraphilic disorders. apply DSM criteria for Sexual Masochism to populations that
were not exclusively forensic, and at least three of these had
Review of Diagnostic Studies in Non-Forensic a substantial component of forensic cases. This implies that
Populations researchers are not using criteria from the DSM to conduct
research on Sexual Masochism and/or that individuals with
Abel, Becker, Cunningham-Rather, Mittelman, and Rouleau Sexual Masochism are not presenting for treatment.
(1988) and Abel et al. (1987) reported on an outpatient popu-
lation of 561 men seeking voluntary evaluation and treatment Review of Studies of Masochistic Behavior
for possible paraphilias in Memphis, Tennessee or in New York in the Community, in Treatment Populations,
City. In the Memphis sample, all categories of paraphilias were and with Regard to Harm
evaluated; in the New York sample, mostly subjects with a diag-
nosis of rape or child molestation were seen. DSM-II and DSM- Incidence of Masochistic Behavior in the Community
III criteria were used, with all subjects reporting recurrent, repeti-
tive urges to carry out deviant sexual behaviors. Subjects were not Moser and Levitt (1987) reported that general population sur-
included in the research solely because they had committed the veys had not established the proportion of the general popula-
paraphilic behavior. One-third of this sample was referred from tion that identified as S/M and noted that it was not clear if any
legal or forensic sources, one-third from mental health sources, specific behaviors could be classified as S/M specifically. How-
and one-third from other sources. Of these, 28 men were diag- ever, S & M behavior appears to be fairly common. Kinsey,
nosed with sadism and 17 with masochism. These disorders had Pomeroy, Martin, and Gebhard (1953, p. 678) reported that 26%
occurred in the patient during his lifetime, and there was no of females and 26% of males reported a definite and/or frequent
indication as to which, if any, paraphilia was a focus of concern. erotic response to being bitten. Hunt (1974), in a survey of sex-
Kafka and Prentky (1994) collected data prospectively on ual behavior in the United States involving 2,026 respondents in
63 consecutively evaluated outpatient males. Three men were 26 cities, found that 4.8% of males and 2.1% of females reported
excluded. Thirty-four were seeking treatment for paraphilic ever having obtained sexual pleasure from inflicting pain, and
disorders and 26 for paraphilia-related disorders. A question- 2.5% of males and 4.6% of females from receiving pain. A
naire was used along with a structured interview to establish a recent Australian study (Richters, Grulich, De Visser, Smith, &
diagnosis, which represented a lifetime diagnosis. It was not Rissel, 2003) utilizing a large telephone survey reported that
clear which paraphilia was the focus for treatment. Twelve 2.0% of men and 1.4% of women reported that in the preceding
percent of the paraphilic group was diagnosed with sadism and 12 months they had been involved in bondage and discipline,
9% with masochism. Kafka and Prentky recommended that sadomasochism, or dominance and submission. In another arti-
future studies should utilize structured diagnostic interviews cle, Richters, De Visser, Rissel, Grulich, and Smith (2008)
and blind interviewing techniques. concluded that BDSM (referring to bondage and discipline,
The American Psychiatric Association (1999) in a book ‘‘sadomasochism’’or dominance and submission) was simply a
called Dangerous Sex Offenders reported on some data given as sexual interest and not a pathological symptom of past abuse or
a personal communication from Dr. Gene Abel on a sample of of difficulty with‘‘normal sex.’’
2,129 patients evaluated at 140 sexual treatment clinics in North Crépault and Couture (1980), using a semistructured inter-
America, who presumably answered questions on the Abel view and a self-administered questionnaire, reported on the
Assessment of Sexual Interest (Fischer, 2000), although this erotic fantasies of 94 men occurring during heterosexual activ-
was not explicitly stated. In this sample, 2.3 percent reported ity; 11.7% reported that they had had a fantasy of being humil-
they had engaged in sadism and 2.5% in masochism, but the iated, and 5.3% where they were beaten up. A recent systematic
methods and criteria used to obtain this information were not review of the research literature on women’s rape fantasies
described. (Critelli & Bivona, 2008) reported that between 31 and 57% of
Kafka and Hennen (2002, 2003) reported on a population of women had fantasies in which they were forced into sex against
120 consecutively evaluated outpatient males with paraphilias their will and that for 9–17% of women these were a frequent or
(N = 88, including 60 sex offenders) or paraphilia-related dis- favorite fantasy experience.
orders (N = 32). Structured interviews and DSM-IV criteria Thus, although there is not a lot of survey information on
were used to make lifetime diagnoses. Eleven percent of the sexual masochistic or sadomasochistic behavior, it has been
paraphilic sample had Sexual Masochism and 5% Sexual reported in from 1 to 5% of the U.S. and Australian population.
Sadism. They noted that there were no rating instruments with Sadomasochistic sexual fantasies during sexual intercourse
123
352 Arch Sex Behav (2010) 39:346–356
were reported by 10% of men in a Canadian study and a large Studies of survivors of this practice indicate that nearly all indi-
percentage of females (from 31 to 57%) were reported to have viduals fantasize about masochistic scenarios as they engage in
rape fantasies in a recent review of the literature. it (Hucker, 2008). Fifty fatalities yearly from this activity are
reported in the United States (Litman & Swearingen, 1972) and
Presentation of Patients with Sadomasochism case reports of death from electrocution during other autoerotic
or Masochism for Treatment procedures exist (Cairns, 1981).
Thus, studies which have been done show generally good
Freund, Seto, and Kuban (1995) reported on a group of 54 male psychological and social functioning compared with the general
masochists seen at their sexology clinic. They reported that population and that sadomasochistic activity may be associated
masochistic patients appeared to be relatively rarely seen in a with reductions in physiological stress and increase in relation-
sexology clinic and that, in contrast to individuals who had pre- ship closeness. There are, however, case reports of injury or
sented for treatment of other paraphilias, their masochistic death associated with masochistic activity, and evidence that
patients were predominately self-referred and rarely got into most individuals who engage in or die during erotic or autoerotic
legal trouble because of their paraphilia. asphyxiation have masochistic fantasies.
Spengler (1977, 1983), in a survey of 245 manifestly sado-
masochistic West German men, reported that 20% rejected their Misuse of DSM in Child Custody Proceedings
sadomasochistic orientation, 70% accepted it, and 9% ‘‘didn’t and Discrimination
know.’’Ninety percent had never visited a doctor, psychiatrist,
or psychologist because of their sadomasochistic deviation, but Klein and Moser (2006) described the case of the misuse by
10% reported doing this at least once. Moser and Levitt (1987) forensic professionals of the DSM criteria in a child custody suit,
reported on the results of a questionnaire given to 178 men self- suggesting that these not infrequent cases should be an impetus
defined as S & M. Most respondents were satisfied with the S & to the editors of the DSM to reevaluate its classification of atypi-
M part of their sexuality, but 6% expressed distress concerning cal sexual behavior as pathological and to strengthen its warn-
their behavior and 16% had sought help from a therapist for their ings against misuse. Wright (2006) presented information on vio-
S & M desires. Thus, according to the above studies, patients lence and discrimination against SM-identified individuals; of
with Sexual Masochism infrequently see mental health pro- 1017 SM individuals surveyed, 36% had suffered some sort of
fessionals for concerns about this behavior. violence or harassment because of their SM practices, and 30%
had been victims of job discrimination.
Is There Evidence of Harm from Sadomasochistic
or Masochistic Behavior? Hypoxyphilia
Most studies of individuals practicing sadomasochism in the The DSM-V paraphilias workgroup discussed this entity and
community have shown evidence of good psychological and decided, because of the dangerousness of this activity and its
social function, as measured by higher educational level, income, appearance as a clinical syndrome, that this might merit inclu-
and occupational status compared with the general population sion as a separate paraphilic disorder. An advisor to the sub-
(Breslow, Evans, & Langley, 1985; Moser & Levitt, 1987; workgroup has prepared an analysis of the literature (Hucker,
Sandnabba, Santtila, & Nordling, 1999; Santtila, Sandnabba, & 2009). Hucker recommended the use of the term ‘‘asphyxio-
Nordling, 2000). Weinberg (2006) concluded his review of the philia’’ given the observation that it appeared that individuals
social and psychological literature by saying that ‘‘…sociolog- engaging in this behavior primarily obtained sexual arousal
ical and social psychological studies see SM practitioners as through restriction of breathing rather than the subjective expe-
emotionally and psychologically well balanced, generally com- rience of oxygen lack. He also recommended keeping this diag-
fortable with their sexual orientation, and socially well adjus- nosis under the general rubric of Sexual Masochism.
ted’’(p. 37). A recent study by Sagarin, Cutler, Cuther, Lawler-
Sagarin, and Matuszewich (2009) examining hormone levels Relationship and Cultural Context
and psychological measures of relationship closeness in sub-
jects before and after participating in sadomasochistic activities Mitchell and Graham (2008) raised the issue that relationship
reported reductions in physiological stress as measured by corti- influences are not considered in the diagnosis of sexual disorders
sol and increases in relationship closeness among participants and Tiefer (2004) and Tiefer, Brick, and Kaplan (2003) noted that
who reported their SM activities went well. both relationship and cultural context are important in assess-
Hypoxyphilia, or the production of sexual excitement by ing and treating sexual disorders. Given that Sexual Masochism is
asphyxia, has been reported in several studies of Sexual Mas- one of the paraphilias that could occur in the context of a rela-
ochism (Alison, Santtila, Sandnabba, & Nordling, 2001; Freund tionship (along with Transvestic Fetishism, and perhaps some of
et al., 1995; Santtila, Sandnabba, Alison, & Nordling, 2002). the other unnamed paraphilias), it might make sense to consider
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Arch Sex Behav (2010) 39:346–356 353
adding a specification as to whether Sexual Masochism occurred 3. The current criteria for Sexual Masochism in the DSM do
in the context of a relationship. not apply to the vast majority of individuals who are prac-
ticing this behavior. There clearly are some individuals
who present for treatment for Sexual Masochism, where
Recommendations and Discussion
such behavior has become out of control and a source of dis-
tress or dysfunction, and the current diagnostic criteria are
Should Sexual Masochism Be Retained in the DSM?
appropriate for these individuals.
4. Some of the concerns of those in the S & M community
Yes, for the following reasons:
regarding the misuse of the DSM to diagnose them could be
1. While masochistic and/or sadomasochistic behavior occur addressed by strengthening caveats circumscribing the appli
with some frequency in the population and is associated cation of the DSM in clinical or in forensic matters, par-
with generally good psychological or social functioning, ticularly as regards S & M.
there are a very small number of cases where masochistic
fantasy and behavior result in severe harm or even death.
Should There Be Any Change in the Diagnostic Criteria?
These cases clearly indicate a sexual interest pattern that
has become pathological. Since so little is know about this
Yes. Please see Table 4 for the change I am recommending and
behavior, further research is indicated, and inclusion in the
the reason for it. Otherwise, I think that the current criteria do a
DSM would facilitate this.
good job of defining Sexual Masochism that has become path-
2. Although there are only a small number of studies that report
ological and should not be changed. Further, the paraphilias sub-
on the occurrence of sexual masochism in forensic popu-
group will be discussing dimensional assessment, and this may
lations, one of these (Hill et al., 2006) reported that, of 166
afford the opportunity to depict Sexual Masochism on some
sexual murderers, 5.4% received a diagnosis of sexual mas-
continuum, or to qualify this disorder as mild, moderate, severe,
ochism, and 14.8% of those with sexual sadism also had
or extreme.
sexual masochism. Further, because of the association of
sadism with masochism, and because the studies of forensic Acknowledgments This article was prepared with the assistance of
populations did not use structured diagnostic inventories, the Dr. Meg Kaplan. The author is a member of the DSM-V Workgroup on
occurrence of sexual masochism in forensic populations Sexual and Gender Identity Disorders (Chair, Kenneth J. Zucker, Ph.D.).
could be substantially higher. In my opinion, retention of the I wish to acknowledge the valuable input I received from members of my
Paraphilias subworkgroup (Ray Blanchard, Marty Kafka, and Niklas
diagnosis of Sexual Masochism in the DSM would allow for Långström) and Kenneth J. Zucker. Reprinted with permission from the
further research to be done on Sexual Masochism in forensic Diagnostic and Statistical Manual of Mental Disorders V Workgroup
populations. Reports (Copyright 2009), American Psychiatric Association.
Table 4 Comparison of DSM-IV-TR and proposed DSM-V diagnostic criteria for sexual masochism
DSM-IV-TR Proposed for DSM-V
Sexual Masochism Sexual Masochism

A. Over a period of at least 6 months, recurrent, intense A. Over a period of at least six months, recurrent, intense
sexually arousing fantasies, sexual urges, or behaviors sexually arousing fantasies, sexual urges, or behaviors
involving the act (real, not simulated) of being humiliated, involving the act of being humiliated, beaten, bound,
beaten, bound, or otherwise made to suffer or otherwise made to suffer
B. The fantasies, sexual urges, or behaviors cause clinically B. The fantasies, sexual urges, or behaviors cause
significant distress or impairment in social, occupational, clinically significant distress or impairment in social,
or other important areas of functioning occupational, or other important areas of functioning
C.
Specify if:
With Asphyxiophilia (Sexually Aroused by Asphyxiation)
Note: I concluded that sexual masochism should be retained in the DSM-V, and that the phrase ‘‘real, not simulated’’ should be deleted from the A
Criterion as this did not appear to add any real distinction and because I could find no explanation for the continued inclusion of this phrase was found in
the literature. The DSM paraphilias subworkgroup discussed hypoxyphilia and asked Dr. Steven Hucker to prepare an analysis of the literature and his
recommendations for suggested diagnostic criteria, which he did (Hucker, 2009). Hucker, arguably the foremost authority on sexual masochism and
on hypoxyphilia, argued convincingly to the paraphilias workgroup that it was not clear in this disorder that sexual arousal was, in fact, a result of
oxygen deprivation; rather, it appeared that individuals would primarily obtain sexual arousal by restricting their breathing which secondarily resulted
in the subjective experience of oxygen deprivation. He suggested that the term asphyxiophilia, coined previously by Money (1986) was more accurate
and should be used. He also suggested that the available research did not provide sufficient evidence for making asphyxiophilia a separate category or
code, and that it should be retained, but under the main diagnosis of sexual masochism as a specifier
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354 Arch Sex Behav (2010) 39:346–356
Appendix 1: Sexual Masochism in the DSM Appendix 2: Sexual Masochism in the ICD
Diagnostic Criteria for Sexual Masochism from DSM-I to The ICD-9 and ICD-10 Criteria for Sexual Sadism and
DSM-IV-TR. Sexual Masochism and the ICD-10 Diagnostic Criteria for
Research for Sadomasochism
The ICD-9-CM Diagnostic Criteria for Sadism and Mas-
DSM-I (American Psychiatric Association, 1952)
ochism (World Health Organization, 1989) (p. 229) are:
There is no mention of Sexual Masochism in DSM-I. 302.8 Other specified psychosexual disorders
302.83 Sexual masochism
DSM-II (American Psychiatric Association, 1968) 302.84 Sexual sadism
The only mention of Masochism occurs under the categori- The ICD-10 International Statistical Classification of Dis-
zation of Sexual Deviations (302.7): eases and Related Health Problems, Tenth Revision (World
Sexual Deviations. This category is for individuals whose Health Organization, 1992) (p. 367) criteria are:
sexual interests are directed primarily towards objects other than F65 Disorders of sexual preference
people of the opposite sex, toward sexual acts not usually asso- Includes: Paraphilias
ciated with coitus, or toward coitus performed under bizarre F65.5 Sadomasochism
circumstances as in necrophilia, pedophilia, sexual sadism, and A preference for sexual activity which
fetishism. Even though many find their practices distasteful, involves the infliction of pain or humiliation,
they remain unable to substitute normal sexual behavior for or bondage. If the subject prefers to be the
them. This diagnosis is not appropriate for individuals who per- recipient of such stimulation this is called
form deviant sexual acts because normal sexual objects are not masochism; if the provider, sadism. Often an
available to them. (p. 44) individual obtains sexual excitement from
both sadistic and masochistic activities.
DSM-III (American Psychiatric Association, 1980) Masochism
Sadism
Sexual masochism is classified as one of the paraphilias, with The ICD-10 Classification of Mental and Behavior Dis-
one of the following criteria necessary for the diagnosis: orders Diagnostic criteria for research (World Health Orga-
(1) A preferred or exclusive mode of producing sexual excite- nization, 1993) are:
ment is to be humiliated, bound, beaten, or otherwise made F65.5 Sadomasochism (p. 137)
to suffer.
A. The general criteria for disorders of sexual
(2) The individual has intentionally participated in an activity
preference (F65) must be met.
in which he or she was physically harmed or his or her life
B. There is preference for sexual activity, as recipient
was threatened, in order to produce sexual excitement.
(masochism) or provider (sadism), or both, which
involves at least one of the following:
DSM-III-R (American Psychiatric Association, 1987)
(1) pain;
(2) humiliation;
The diagnostic criteria for sexual masochism were revised as
(3) bondage.
follows:
C. The sadomasochistic activity is the most impor-
A. Over a period of at least six months, recurrent intense sex-
tant source of stimulation or is necessary for
ual urges and sexually arousing fantasies involving the act
sexual gratification.
(real, not simulated) of being humiliated, beaten, bound, or
otherwise made to suffer. F65 Disorders of sexual preference (p. 135)
B. The person has acted on these urges, or is markedly dis-
G1. The individual experiences recurrent intense sex-
tressed by them.
ual urges and fantasies involving unusual objects
of activities.
DSM-IV and DSM-IV-TR (American Psychiatric G2. The individual either acts on the urges or is
Association, 1994, 2000) markedly distressed by them.
G3. The preference has been present for at least
See Table 4. 6 months.
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Arch Sex Behav (2010) 39:346–356 355
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Arch Sex Behav (2010) 39:357–362
DOI 10.1007/s10508-009-9558-7
ORIGINAL PAPER
The DSM Diagnostic Criteria for Fetishism

Martin P. Kafka

Abstract The historical definitions of sexual Fetishism are Introduction

reviewed. Prior to the advent of DSM-III-R (American Psychi-
atric Association, 1987), Fetishism was typically operationally Fetishism, as a technical descriptor of atypical sexual behav-
described as persistent preferential sexual arousal in association ior, was noted in the writings of the well-known nineteenth
with non-living objects, an over-inclusive focus on (typically century French psychologist Alfred Binet (1857–1911) (Binet,
non-sexual) body parts (e.g., feet, hands) and body secretions. In 1887) as well as prominent European sexologists Richard von
the DSM-III-R, Partialism, an ‘‘exclusive focus on part of the Krafft-Ebing (1840–1902) (Krafft-Ebing, 1886), Havelock
body,’’ was cleaved from Fetishism and added to the Paraphilia Ellis (1859–1939) (Ellis, 1906), and Magnus Hirschfeld (1868–
Not Otherwise Specified category. The current literature re- 1935) (Hirschfeld, 1956). In their seminal writings, all of the
viewed suggests that Partialism and Fetishism are related, can aforementioned sexologists used the terms ‘‘fetish’’ and ‘‘fe-
be co-associated, and are non-exclusive domains of sexual be- tishism’’ to specifically describe an intense eroticization of
havior. The author suggests that since the advent and elaboration either non-living objects and/or specific body parts that were
of the clinical significance criterion (Criterion B) for designating symbolically associated with a person. Fetishes could be non-
a psychiatric disorder in DSM-IV (American Psychiatric Asso- clinical manifestations of a normal spectrum of eroticization
ciation, 1994), a diagnostic distinction between Partialism and or clinical disorders causing significant interpersonal diffi-
Fetishism is no longer clinically meaningful or necessary. It is culties. Ellis (1906) observed that body secretions or body
recommended that the diagnostic Criterion A for Fetishism be products could also become fetishistic expressions of ‘‘erotic
modifiedtoreflect thereintegrationofPartialism and that afetish- symbolism.’’ Freud (1928) considered both body parts (e.g.,
istic focus on non-sexual body parts be a specifier of Fetishism. the foot) or objects associated with the body (e.g., shoes) as
fetish objects.
Keywords DSM-V Fetishism Partialism Paraphilia For the purposes of this review, a ‘‘broader’’ historically-
based core definition for Fetishism will include intense and
recurrent sexual arousal to: non-living objects, an exclusive
focus on body parts or body products.
Methodology
I performed an Internet-based literature search using the terms

‘‘fetish,’’ ‘‘fetishism,’’ ‘‘partialism,’’ ‘‘urophilia,’’ ‘‘urolagnia,’’
‘‘undinism,’’ ‘‘coprophilia,’’ and ‘‘coprolagnia’’ utilizing both
PubMed (1948–2008) and PsycINFO (1872–2008) databases
M. P. Kafka (&)
through October 2008. I reviewed contemporary sexology book
Department of Psychiatry, McLean Hospital, 115 Mill Street,
Belmont, MA 02478, USA chapters and primary sources, whenever possible, for infor-
e-mail: [email protected] mation regarding European sexologists (in English language
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358 Arch Sex Behav (2010) 39:357–362
translated texts). In relevant publications, I reviewed referenced Specified (302.9). I have been unable to locate American
articles as well as those that did not appear during a computer- Psychiatric Association working papers that might have
ized search. more specifically defined the rationale for the separation of
Partialism from Fetishism.
Fetishism and the Diagnostic and Statistical Manuals In the DSM-III-R, the core of criterion A for Fetishism (in-
tense sexual arousal to non-living objects) remained the same as
In the second edition of the Diagnostic and Statistical Man- in DSM-III but additional qualifying diagnostic criteria were
ual of Mental Disorders (DSM) (American Psychiatric Asso- added (Criterion B), as were true for all the paraphilic diagnoses.
ciation, 1968), Fetishism was included as a ‘‘sexual devia- Criterion B was added to emphasize that psychiatric disorders
tion,’’ but it was not specifically operationally defined. A or diagnoses had to include clinically significant distress or im-
definition for sexual deviations is offered: pairment in functioning as essential elements.
In the DSM-III-R, Fetishism was operationally defined as:
This category is for individuals whose sexual interests are
directed primarily toward objects other than people of the A. Over a period of at least 6 months, recurrent intense sexual
opposite sex, toward sexual acts not usually associated urges and sexually arousing fantasies involving the use of
with coitus, or toward coitus performed under bizarre cir- nonliving objects by themselves (e.g., female undergar-
cumstances as in necrophilia, pedophilia, sexual sadism, ments).
and fetishism. Even though many find their practices dis-
Note: The person may at other times use the nonliving
tasteful, they remain unable to substitute normal sexual be-
object with a sexual partner.
havior for them. This diagnosis is not appropriate for indi-
viduals who perform deviant sexual acts because normal B. The person has acted on these urges, or is markedly dis-
sexual objects are not available to them. tressed by them.
C. The fetishes are not only articles of clothing used in cross-
This definition of Fetishism was abridged in the third edi-
dressing (transvestic fetishism) or devices designed for
tion of the DSM (American Psychiatric Association, 1980)
the purpose of tactile genital stimulation (e.g., vibrator).
and a more circumscribed diagnostic criterion A for Fetish-
ism (302.81) was operationally defined: In the brief discussion section preceding the formal diag-
nostic criteria in DSM-III-R, however, there is no longer any
A. The use of non-living objects (fetishes) is a repeatedly
mention of body products (or body parts) as associated with
preferred or exclusive method of achieving sexual ex-
the diagnosis of Fetishism. The diagnostic manual continues
citement.
to note: ‘‘Among the more common fetish objects are bras,
B. The fetishes are not limited to articles of female clothing
women’s underpants, stockings, shoes, boots and other wear-
used in cross-dressing (Transvestism) or the objects de-
ing apparel’’ (American Psychiatric Association, 1987, p. 282).
signed to be used for the purpose of sexual stimulation
The diagnostic separation of Partialism (intense, persis-
(e.g., vibrator).
tent, and ‘‘exclusive’’ sexual arousal to a non-genital body
Despite this more circumscribed definition for Fetishism part) from Fetishism (intense and persistent sexual arousal
described in DSM-III, in the clinical description of Fetishism to non-living objects, including some body products), and
that precedes the actual specific diagnostic criteria noted above, the former’s inclusion in the Paraphilia Not Otherwise Spec-
the DSM-III text noted: Fetishes tend to be articles of clothing, ified category has continued in the DSM-IV and DSM-IV-TR
such as female undergarments, shoes and boots, or, more rarely, (American Psychiatric Association, 1994, 2000).
parts of the body such as hair or nails (p. 268, my emphasis). The descriptive paragraph and diagnostic criteria for Fetish-
Technically, hair and nails are body products but they ism in DSM-IV and DSM-IV-TR are identical. The only changes
are also ‘‘non-living objects’’ consistent with the DSM-III in diagnostic criteria were to eliminate the qualification note as-
definition of Fetishism. Feet, hands, or other typically non- sociated with Criterion A and to add further clinical significance
sexualized parts of the body are not ‘‘non-living objects,’’ variables to Criterion B consistent with the other paraphilic dis-
however, and there was no diagnostic entity offered in DSM- orders.
III to account for persons whose fetishism-like clinical dis- In the DSM-IV, Fetishism was operationally defined as:
order was delimited by an exclusive focus on non-sexual
A. Over a period of at least 6 months, recurrent, intense sexu-
body parts, such as hands or feet. Such a diagnosis, Partial-
ally arousing fantasies, sexual urges, or behaviors involving
ism, an ‘‘exclusive focus on part of body,’’ was included in the
the use of non-living objects (e.g., female undergarments).
publication of the DSM-III-R (American Psychiatric Asso-
B. The fantasies, sexual urges, or behaviors cause clini-
ciation, 1987). Inasmuch as there was inadequate empirical
cally significant distress or impairment in social, occu-
evidence at that time as to the distinct diagnostic status of
pational, or other important areas of functioning.
Partialism, it was included as a Paraphilia Not Otherwise
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Arch Sex Behav (2010) 39:357–362 359
C. The fetish objects are not limited to articles of female To apply the term to a living part of the human body (hair
clothing used in cross-dressing (as in Transvestic Fetish- excluded) at once makes the practical definition impossible,
ism) or devices designed for the purpose of tactile geni- as one would appreciate after a little reflection. Would a man
tal stimulation (e.g., a vibrator). who cannot bring himself to have coitus with a woman who
lacks breasts…be termed a ‘‘breast fetishist’’? Or can all
In essence, because of a paucity of published data and the
heterosexual males be said to have a fetish for females? In
relative clinical rarity of fetishes as diagnostic disorders (Chalk-
this way lies confusion. We prefer to limit fetishism to the
ley & Powell, 1983; Curran, 1954; Gebhard, Gagnon, Pomeroy,
inanimate, where it defines a clear-cut displacement phe-
& Christenson, 1965), the DSM-based core descriptive diag-
nomena. For exaggerated importance given to various parts
nostic criteria for Fetishism (Criterion A) have been essentially
or configurations of the human anatomy, we prefer to use
maintained for the past 30 years. In addition, this more circum-
another term—we suggest ‘‘partialism.’’ Thus, some men
scribed operational definition of Fetishism has been incorpo-
may have a fetish for panties, hair, shoes or other inanimate
rated in the International Statistical Classification of Diseases
objectswhichareintimatelyassociatedwiththehumanbody
and Related Health Problems-Tenth Edition (ICD-10), pub-
but which may be removed from it, and other men may have
lished by the World Health Organization (1992). Partialism is
a fixation on such things as redheads, huge breasts, thinness
not specifically included in the diagnostic nomenclature of the
or fatness. As with fetishism, partialism may become a sine
ICD-10.
qua non (as a man who is impotent with any female who is
not red-headed), but, by definition cannot go further….
Partialism and Fetishism Whereas partialism is limited to the possible variations of the
human body, virtually anything can be involved in fetishism.
Inasmuch as I will be discussing Partialism and whether it should (pp. 415–416)
retain its distinction as a separate and distinct psychiatric disorder
A contemporary literature review of Partialism reveals no
from Fetishism in DSM-V, I will review the origin of this term.
empirical data under that search term but the diagnosis is men-
As best as I can ascertain, the term ‘‘partialism’’ originated in the
tioned in several texts (Cantor, Blanchard, & Barbaree, 2009;
writings of a German neurologist/sexologist, Albert Eulenberg
Davis, 1950a; Gebhard et al., 1965; McWilliams, 2006; Milner
(1840–1917), whose sexological publications (all in German lan-
& Dopke, 1997; Milner, Dopke, & Crouch, 2008).
guage) were published in the very late nineteenth century and
early twentieth century. Eulenberg is credited by Wilhelm Stekel
Is There New Empirical Information About Partialism
(1886–1940) with developing the descriptive term partialism and
and Fetishism Relevant to DSM-V?
Stekel’s use of the term partialism described sexual attractions to
body parts but, in contrast to fetishism, not of the sufficient
Apart from single or very small sample case reports, before
intensity so as to impair sexual intercourse.
1990, the only descriptive empirical articles or clinical sam-
The true fetish lover dispenses with a sexual partner and ples that included more than 25 men with Fetishism were by
gratifies himself with a symbol. This symbol can be Krafft-Ebing (1965), Stekel (1952), Gosselin and Wilson
represented by a piece of clothing, a part of the partner’s (1980), and Chalkley and Powell (1983). All of these inves-
body (pubic hair, nails braid or pigtail) or any object tigators used the ‘‘broader’’ or an ambiguous definition of
used by the other person. (Stekel, 1952, pp. 12–13) Fetishism.
Gosselin and Wilson’s sample (n = 125) was derived from
Stekel commented that ‘‘the most widespread form of par-
volunteers in membership organizations such as The Mackin-
tialism is preference for feet’’ (p. 169) and, although he presents
tosh Society for rubber fetishists (n = 87 and the Atomage
an elaborated case of Calf Partialism, Sadism, and Kleptomania
correspondence club for leather fetishists (n = 38). Chalkey
(pp. 133–168), he also presented an elaborated Analysis of a
and Powell’s modestly sized clinical sample was derived from
Foot Fetishist (pp. 225–275). Thus, for Stekel, an erotic pref-
carefully culling over 20 years of discharge diagnoses from
erences for part of the body can become a fetish when the body
two major hospitals in London.
part is preferred to or replaces sexual intercourse.
From these samples, the clinical cases described by Krafft-
This definition for Fetishism and its distinction from Partialism
Ebing, Ellis, Hirschfeld, and Stekel and some additional
was further endorsed by Gebhard et al. (1965). Their sample in-
contemporary data (Junginger, 1997; Scorolli, Ghirlanda,
cluded 888 predominantly incarcerated sexual offenders. Only 10
Enquist, Zattoni, & Jannini, 2007; Weinberg, Williams, &
of these men, however, were adjudicated for fetish-motivated theft
Calhan, 1994, 1995), several consistent clinical observations
(0.011% of the sample). All of these men had stolen inanimate
about Fetishism have emerged:
objects, typically women’s undergarments, i.e., typical fetish non-
living objects. In discussing fetishism, I suggest: They comment in 1. Many males who self-identify as fetishists in community
discussing fetishism or convenience samples do not necessarily report clinical
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360 Arch Sex Behav (2010) 39:357–362
impairment in association with their fetish or fetish- primary interests of the respondents. When asked more specifi-
associated behaviors (Chalkley & Powell, 1983; Goss- cally what was most sexually arousing, their respondents listed
elin & Wilson, 1980; Scorolli et al., 2007; Weinberg clean feet (60%), boots (52%), shoes (49%), sneakers (47%),
et al., 1994). Thus, many ‘‘fetishists’’ do not meet criteria and smelly socks (45%). These percentages suggest significant
for a psychiatric diagnosis of Fetishism that is associated overlap amongst these fetishistic objects and a body part (the
with significant personal distress or psychosocial (includ- foot). A total of 59 men (22.5%) considered their fetishistic
ing sexual) role impairment (Criterion B). interest and behavior was associated with significant emotional
2. Fetishes, as with other paraphilic disorders, are almost or sexual impairment as well as loneliness, low self-esteem,
exclusively male disorders. Clinically significant fetishes depressive affect, shame and guilt, sexual inadequacy, and prob-
typically develop in childhood or early adolescence and lems associated with intimate relationships. Although diag-
are usually persistent sexual preferences. nostic threshold criteria for clinically significant impairment
3. Fetishes can co-occur with other paraphilic behaviors, were not specifically applied in this study, it would certainly
especially ‘‘sadomasochism’’ (Brown, 1983; Buhrich, 1983; appear that these men would meet the threshold for a DSM-IV-
Gosselin & Wilson, 1980; Spengler, 1977; Weinberg et al., TR-based psychiatric diagnosis of Fetishism. This would be the
1994) and transvestic fetishism (Blanchard, Racansky, & largest contemporary sample of ‘‘clinical’’ fetishists or partial-
Steiner, 1986; Freund, Seto, & Kuban, 1996; Wilson & ists to date.
Gosselin, 1980) but are uncommon amongst sexual offender Scorolli et al. (2007) tried to estimate the relative frequency of
paraphiliacs (Abel & Osborn, 1992; Gebhard et al., 1965). fetishes in an international community sample by utilizing an
4. Men with clinically significant fetishes may steal and col- Internet search through Yahoo! groups whose name or descrip-
lect their fetishistic objects (Chalkley & Powell, 1983; tion included the word ‘‘fetish.’’ From a list of 2,938 groups, they
Gebhard et al., 1965; Krafft-Ebing, 1965; Revitch, 1978; delimited their search to those whose title suggested most un-
Stekel, 1952). ambiguously a fetish as a ‘‘sexual preference.’’ They reported on
5. A male with a single fetish may have multiple fetishes, 381 groups with an estimated 150,000 members. Given that they
including preferential sexual arousal to both body parts were unable to ascertain how many members subscribed to more
and non-living objects (Chalkley & Powell, 1983; Scorolli than one group, they very conservatively estimated that their data
et al., 2007; Weinberg et al., 1994). would include information from a minimum of about 5,000
6. Female undergarments, body parts especially feet, individuals. The two most common fetish categories included
footwear including socks, shoes and boots, and leather objects associated with the body (33% of the sample) and body
objects are common fetishes in contemporary commu- parts or features (30% of the sample). In the objects sub-group, the
nity or convenience samples of self-identified fetishists most common objects were objects worn on legs and buttocks,
(Gosselin & Wilson, 1980; Junginger, 1997; Scorolli 33%; foot wear, 32%; and underwear, 12%. In the body parts or
et al., 2007; Weinberg et al., 1994). features sub-group, the most common body parts were feet and
7. Fetishism is a multi-sensory sexual outlet as fetishists may toes (47%). In reporting on combinations of categories, they re-
smell, taste, touch, insert, rub or be visually aroused by ported that body parts and objects associated with the body were
their fetishistic object or body part (Chalkley & Powell, the most frequent combination. Scorolli et al. noted their survey’s
1983; Gosselin & Wilson, 1980; Hirschfeld, 1956; Krafft- strengths (large sample, enhanced freedom of sexual self expres-
Ebing, 1965; Scorolli et al., 2007; Weinberg et al., 1994). sion on the Internet, an observational survey, not an administered
questionnaire) as well as their limitations (sampling bias, no con-
In the more recent reports, Fetishism and Partialism can trol or comparison group, possible inaccurate reporting, higher
co-occur, at least in community-based or convenience sam- socioeconomic and educational status of Internet subscribers).
ples of males self-identified as fetishists (Scorolli et al., 2007; Scorolli et al. had no means to ascertain degrees of impairment
Weinberg et al., 1994). from their sample.
The reports of Weinberg et al. (1994, 1995) and Scorolli et al. These two reports are not specifically clinically-derived
(2007) are particularly noteworthy because of their sample size and each contains some inherent sample biases. Nonetheless,
(n = 262, and n [ 5,000, respectively). In the ‘‘pre-Internet neither report empirically supports a clear distinction be-
era,’’ Weinberg et al., like Gosselin and Wilson (1980), gathered tween fetishism and partialism. In fact, both surveys support
data from an organization of self-described fetishist practitio- both a significant continuum and overlap between Partialism
ners. Weinberg et al. surveyed a predominantly homosexual/ and Fetishism.
bisexual foot fetishist group called the ‘‘Foot Fraternity.’’ In
their data set, it was clear that their subjects did not make a Fetishism and Body Products
specific distinction between body parts and non-living objects as
they described their fetish objects and behaviors. Thus, Wein- As was noted in DSM-III, body products, such as hair or finger-
berg et al. concluded that male feet and footwear were the nails, can become obligatory fetish objects. Other examples of
123
Arch Sex Behav (2010) 39:357–362 361
body products that have been described and categorized as non-living objects as well as exclusive focus on body parts as
fetishes include sweat, urine (urophilia, urolagnia: Davis, 1950b; long as, in the latter case, there was significant impairment
Ellis, 1906) orundinism (Denson, 1982), blood, vampirism (Prins, noted in interpersonal or especially heterosexual coital rela-
1985; Vanden Bergh & Kelly, 1964), necrophilia (Rosman & tions. The broader criteria for Fetishism, as historically defined,
Resnick, 1989), and feces (coprophilia or coprolagnia; Ellis, are consonant with the most recent data available (reviewed
1906). There is insufficient extant clinical data, however, to above) from fetishism practitioners, some of whom also report
definitively characterize these rare paraphilias as fetishes. significant distress and psychosocial impairments in associ-
ation with their fetish disorder.
It is noteworthy that Criterion B was absent in defining a
Recommendations for the DSM-V Diagnosis of Fetishism diagnostic threshold for paraphilic disorders in DSM-III and
DSM-III-R when Partialism was initially distinguished from
I suggest, based on the aforementioned review of the avail- Fetishism. As long as the threshold for personal distress or
able empirical literature, that the diagnostic criterion A for significant impairment of social or interpersonal functioning
Fetishism as a paraphilic disorder be modified to reflect the remains as a standard threshold for paraphilic disorders, the
reintegration of Partialism within the Criterion A operational distinction between a non-sexual body part or an inanimate
definition for Fetishism and as a specifier of Fetishism (see object associated with the human body produces an unnec-
Table 1). essary division for research in fetishistic behaviors.
Advantages and Disadvantages of Changing the DSM-V Disadvantages

Diagnostic Criteria for Fetishistic Disorder
During the past 30 years, the DSM-based operational defi-
Advantages nition for Fetishism as a psychiatric disorder has been re-
markably consistent and clearly defined. The clinical signif-
Fetishism as a psychiatric diagnosis remains uncommon or, icance qualifier (Criterion B) has been added as a major (and
perhaps, under-reported because clinicians accumulate too few important) addition to the diagnostic criteria to determine a
cases for publication. As is the case with many paraphiliacs, there paraphilic disorder or diagnosis as opposed to an atypical
may be many practitioners of variant sexual behaviors who do sexual or behavioral proclivity. Inasmuch as Fetishism has
not meet the threshold for significant impairment in psychosocial remained relatively uncommon as a researched and clinically
or sexual functioning. Fetishism as a condition ascertained in reported psychiatric diagnosis, returning the boundaries for
community or convenience samples, however, strongly support a this disorder to its historical precedent could lead to changes
continuum of fetishistic behaviors across current categories (both in research criteria of this condition and to its subsequent
non-living objects and body parts) as well as varying degrees of ascertainment in our community.
clinically significant distress or impairment in social, occupa- To suggest that the diagnostic criteria be altered primarily
tional or other important areas of functioning. on the basis of four publications (Chalkley & Powell, 1983;
For approximately 100 years prior to the publication of Scorolli et al., 2007; Weinberg et al., 1994, 1995) may be pre-
DSM-III, the classical definitions for Fetishism included both mature. Reincorporating paraphilic expressions of Partialism
as a specifier for Fetishism could lead to issues associated with
Table 1 Proposed DSM-V diagnostic criteria for Fetishism (302.81)
indistinct boundaries for defining a fetish disorder or lead to false
A. Over a period of at least 6 months, recurrent, intense, sexually positive diagnoses or prevalence estimates because non-path-
arousing fantasies, sexual urges and behaviors involving either ological expressions of fetishism are more likely to be found in
the use of non-living objects and/or a highly specific focus on
non-genital body part(s). larger population samples. This propensity, however, should be
B. The fantasies, sexual urges, and behaviors cause clinically minimized or eliminated as long as diagnostic criteria include
significant distress or impairment in social, occupational, or other an enhanced delineation for significant personal distress or psy-
important areas of functioning. chosocial functional impairment (Criterion B) as a necessary
C. The fetish objects are not limited to articles of clothing used in cross- component for ascertaining and distinguishing a non- or pre-
dressing (as in Transvestic Fetishism) or devices specifically clinical condition from a true-positive DSM-V psychiatric diag-
designed for the purpose of tactile genital stimulation (e.g.,
vibrator).
nosis of Fetishism.
Specify:
Acknowledgments The author is a member of the DSM-V Work-
Body part(s): group on Sexual and Gender Identity Disorders (Chair, Kenneth J.
Non-living object(s): Zucker, Ph.D.). I wish to acknowledge the valuable input I received from
Other: members of my Paraphilias subworkgroup (Ray Blanchard, Richard
Krueger, and Niklas Långström) and Kenneth J. Zucker. Reprinted with
Note: The proposed changes are italicized permission from the Diagnostic and Statistical Manual of Mental
123
362 Arch Sex Behav (2010) 39:357–362
Disorders V Workgroup Reports (Copyright 2009), American Psychi- Gebhard, P. H., Gagnon, J., Pomeroy, W., & Christenson, C. (1965). Sex
atric Association. offenders: An analysis of types. New York: Harper & Row.
Gosselin, C., & Wilson, G. (1980). Sexual variations. London: Faber &
Faber.
Hirschfeld, M. (1956). Sexual anomalies: The origins, nature and treat-
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DOI 10.1007/s10508-009-9541-3
ORIGINAL PAPER
The DSM Diagnostic Criteria for Transvestic Fetishism

Ray Blanchard

Abstract This paper contains the author’s report on trans- section. I have made no changes to the original text, except for
vestism, submitted on July 31, 2008, to the work group charged updating the references.
with revising the diagnoses concerning sexual and gender The original report included my proposal for a revised set
identity disorders for the fifth edition of the American Psychi- of diagnostic criteria. In the year since I submitted my report,
atric Association’s Diagnostic and Statistical Manual of Men- these diagnostic criteria have been further modified by input
tal Disorders (DSM). In the first part of this report, the author from the Paraphilias Subworkgroup of the Sexual and Gender
reviews differences among previous editions of the DSM as Identity Disorders Work Group and from official Advisors to
a convenient way to illustrate problems with the nomenclature the Paraphilias Subworkgroup. Thus, the diagnostic criteria
and uncertainties in the descriptive pathology of transvestism. presented later in this paper are somewhat different from the
He concludes this part by proposing a revised set of diagnostic diagnostic criteria currently being considered by the Para-
criteria, including a new set of specifiers. In the second part, he philias Subworkgroup, and they are likely different from the
presents a secondary analysis of a pre-existing dataset in order criteria that will eventually be approved by the DSM-V Task
to investigate the utility of the proposed specifiers. Force and the Board of Trustees of the American Psychiatric
Association. I have included them because they were part of
Keywords Autogynephilia Cross-dressing DSM-V my original report, and because they help to document the
Fetishism Paraphilia Penile plethysmography evolution of the diagnostic criteria that will eventually form
Transvestism part of the DSM-V.
Introduction
Report on Transvestic Fetishism
On July 31, 2008, I submitted a report on transvestism to the
work group charged with revising the diagnoses concerning There are four key elements in the syndrome of Transvestism
sexual and gender identity disorders for the fifth edition of the (later called Transvestic Fetishism) as described in the DSM.
American Psychiatric Association’s Diagnostic and Statis- These four elements are: (1) cross-dressing (2) associated
tical Manual of Mental Disorders (DSM). That report is re- with sexual arousal (3) in a biological male (4) with a het-
produced in the remainder of this paper, beginning in the next erosexual orientation. There are, of course, cross-dressers
who fall outside this definition: homosexual men who cross-
dress without sexual arousal and perhaps rare women who
R. Blanchard (&)
cross-dress with sexual arousal. The existence of these other
Kurt Freund Laboratory, Law and Mental Health Program,
Centre for Addiction and Mental Health, 250 College St., groups has no necessary bearing on whether the combination
Toronto, ON M5T 1R8, Canada of male sex, heterosexual orientation, cross-dressing, and
e-mail: [email protected] sexual excitement constitutes a distinct syndrome. The con-
sensus of expert clinicians, for almost a century, has been that
R. Blanchard
Department of Psychiatry, University of Toronto, it does. This clinical consensus is supported by the available
Toronto, ON, Canada epidemiological data (Långström & Zucker, 2005).
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364 Arch Sex Behav (2010) 39:363–372
In matters other than the key elements, the diagnostic criteria Subjects were 37 HCD patients and 10 paid heterosexual
in successive versions of the DSM have varied. The diagnostic controls. HCDs were divided into groups according to
criteria for DSM-III (American Psychiatric Association, 1980), their response to a questionnaire item asking the propor-
DSM-III-R (American Psychiatric Association, 1987), DSM- tion of occasions that cross-dressing was erotically arous-
IV (American Psychiatric Association, 1994), and DSM-IV-TR ing during the past year and offering response options
(American Psychiatric Association, 2000) are given in the from always to never. Penile blood volume was monitored
Appendix. In the first part of this report, I review differences while subjects listened to descriptions of cross-dressing
among these DSM versions as a convenient way to illustrate and sexually neutral activities. All HCD groups responded
problems with the nomenclature and uncertainties in the des- significantly more to cross-dressing than to neutral nar-
criptive pathology of transvestism. I conclude this part by pro- ratives (p \ .01); controls did not (p. 452).
posing a revised set of diagnostic criteria, including a new set of
In other words, Blanchard et al. (1986) concluded that trans-
specifiers.1 In the second part, I present a secondary analysis of a
vestites (HCDs) who deny recent or past erotic arousal in asso-
pre-existing dataset––an analysis intended to investigate the
ciation with cross-dressing or applying make-up still tend to
utility of the proposed specifiers.
respond with penile tumescence to fantasies of such activities.
They discussed three possible explanations of the discrepancy
Review between self-reported and objectively measured sexual res-
ponse. The first explanation (which Blanchard et al. did not
DSM-III favor) is that patients intentionally attempt to mislead clinicians
about the persistence of sexual arousal to cross-dressing. The
The diagnostic criteria in DSM-III state that cross-dressing is second explanation is that some transvestites are actually una-
used ‘‘for the purpose of sexual excitement, at least initially in ware of mild and transient penile tumescence accompanying
the course of the disorder’’ (emphasis added). The phrase was cross-dressing. The third explanation is more easily quoted
presumably added so that the diagnosis would capture the many verbatim than summarized:
patients who would have met all the diagnostic criteria for
transvestism at one stage of their lives, but who state that cross- A third possibility is that some HCDs’ erotic response to
dressing now produces only feelings of comfort and relaxation, their usual cross-dressing activities has been extinguished
not sexual arousal (e.g., Benjamin, 1966; Buhrich & Beaumont, through repeated exposure, so that they are strictly accu-
1981; Buhrich & McConaghy, 1977a; Person & Ovesey, 1978; rate when they report that putting on women’s attire or
Wise & Meyer, 1980). An extensive discussion of self-reports make-up produces no discernable penile erection. If this
of diminishing arousal and their possible meaning can be found were the case, then the erotic response to cross-dressing
in Blanchard, Racansky, and Steiner (1986). fantasies in the present study could be partly a function of
Blanchard et al. (1986) examined this self-report phenomenon these fantasies’ novelty. The ability of the phallometric
using phallometric testing, an objective technique for quantifying narratives to elicit penile tumescence, then, could be
erotic interests in human males. In this psychophysiological considered analogous to the animal investigators’ ‘‘Coo-
procedure, the individual’s penile blood volume is monitored lidge Effect’’ (Wilson, Kuehn, & Beach, 1963), a term
while he is presented with a standardized set of laboratory stimuli used to denote the reactivation of copulatory preparedness
depicting potentially erotic objects or situations. Increases in the in sexually exhausted males by a novel receptive female
examinee’s penile blood volume (i.e., degrees of penile erection) (p. 461).
are taken as an index of his relative responsiveness to different In summary, there are many men who report that cross-
classes of stimuli. The abstract of that article states: dressing was once sexually arousing but that it has ceased to be so,
We examined whether an erotic response to cross-dressing and these reports may be accurate (especially if one holds a
fantasies could be detected in heterosexual male cross- narrow view of erotically motivated behavior as behavior that
dressers (HCDs) who verbally denied any erotic arousal in is necessarily accompanied by penile erection). The DSM-III
association with cross-dressing for at least the past year. phrase at least initially in the course of the disorder avoided the
absurd possibility that a man could outgrow the diagnosis of
transvestism in later life simply by failing to experience (or attend
1
Specifiers and subtypes are two different ways of refining DSM diag- to) sexual excitement when he cross-dresses. This was a more
noses. Subtypes define mutually exclusive and cumulatively exhaustive nuanced formulation than that used in later versions of the
phenomenological subgroups within a diagnosis; in contrast, specifiers are DSM.
not meant to be mutually exclusive or cumulatively exhaustive (DSM-IV- The DSM-III also addressed the phenomenon of dimin-
TR, p. 1). The purpose of specifiers, according to the DSM-IV-TR, is to
‘‘provide an opportunity to define a more homogeneous subgrouping of ishing sexual response to cross-dressing in the text: ‘‘In some
individuals with the disorder who share certain features’’ (p. 1). individuals sexual arousal by the clothing tends to disappear,
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Arch Sex Behav (2010) 39:363–372 365
although the cross-dressing continues as an antidote to anxi- the expense of another (erotic arousal at the thought or image of
ety’’ (p. 269). The notion that cross-dressing functions as an oneself as a woman).2 There are certainly transvestites with
‘‘antidote to anxiety’’ was repeated in the text of DSM-III-R (p. strong interests in specific articles of feminine attire, and for
288); in the texts of DSM-IV and DSM-IV-TR, this became whom the differential diagnosis of transvestism vs. fetishism may
‘‘an antidote to anxiety or depression’’ (p. 531 and p. 574, be difficult to make (see Freund, Seto, & Kuban, 1996). There are
respectively). The notion that cross-dressing has anxiolytic also, however, transvestites for whom the physical properties of
effects may have originated with, or have been transmitted women’s attire appear secondary, and for whom the most
through, the work of Ethel Person and Lionel Ovesey. Ovesey important objective involves presenting themselves as women. I
and Person (1976) make the statement, ‘‘there is a tendency in will return to this point later in this report.
some transvestites for the sexuality to drop away, although A minimum duration of six months was added to the diag-
cross-dressing continues as an antidote to anxiety’’ (p. 221). nostic criteria for all the paraphilias, including Transvestic
This statement is repeated almost word-for-word in Person and Fetishism. It is unclear if this (obviously arbitrary) criterion
Ovesey (1978), including the phrase ‘‘antidote to anxiety’’ (p. was added simply to reduce the probability of false positive
307). In any event, it is unclear whether the term anxiety, as diagnoses by requiring more clinical evidence, or whether it
repeatedly used in the DSM, is meant to denote a sense of reflects some notion that deviant sexual interests can occur as
fearful apprehension—as most people would consciously acute phenomena.
experience it—or some emotion specific to transvestites, for The phrase, ‘‘at least initially in the course of the disorder,’’
which anxiety is the best available description. In survey re- was dropped from the diagnostic criteria, perhaps to avoid the
search on transvestites, the respondents do not usually report seeming paradox of a paraphilia without sexual arousal. The
anxiety-reduction as a motivation for cross-dressing, although implication that a transvestite’s diagnosis should change if his
some indicate that they cross-dress to reduce tension or stress sexual response to cross-dressing wanes beyond the point of
(e.g., Buhrich, 1978; Buhrich & McConaghy, 1977b; Crou- subjective awareness is confirmed by this statement in the text:
ghan, Saghir, Cohen, & Robins, 1981; see also Docter &
In some people sexual arousal by clothing tends to
Prince, 1997). It is possible, of course, that some non-para-
disappear, although the cross-dressing continues as an
philic heterosexual or homosexual men (or women) use sex in
antidote to anxiety. In such cases the diagnosis should
the same way.
be changed to Gender Identity Disorder of Adolescence
The diagnostic criteria for transvestism in DSM-III included
or Adulthood, Nontranssexual Type [GIDAANT]. A
the separate criterion, ‘‘Intense frustration when the cross-
small number of people with Transvestic Fetishism, as
dressing is interfered with.’’ This was probably intended as a
the years pass, want to dress and live permanently as
core sign or symptom of transvestism rather than a distress or
women, and desire surgical or hormonal sex reassign-
impairment criterion. It is not the same as impaired interper-
ment. In such cases the diagnosis should be changed to
sonal or social functioning as a consequence of transvestism,
Transsexualism. (DSM-III-R, pp. 288–289)
and it is obviously quite different from remorse or discontent
with being transvestic. The DSM-III-R was the only version of the DSM to offer
In DSM-III, Transsexualism was an exclusionary criterion the diagnosis of GIDAANT. It was therefore the only version
for Transvestism. This is consistent with a common taxonomic to suggest this alternative diagnosis for patients whose sexual
view at that time, namely, that transsexualism, transvestism, response to cross-dressing has disappeared while the cross-
and homosexuality constitute three, completely different enti- dressing itself continued at the same or even higher rate.
ties with mutually exclusive etiologies. In DSM-III-R, the criterion, ‘‘Intense frustration when the
cross-dressing is interfered with,’’ was dropped. The reasons
DSM-III-R for this are not apparent.
The writers of DSM-III-R added the beginnings of a separate
In this version of the DSM, the name of the diagnosis was distress/impairment criterion (Criterion B) to all the paraphilias;
changed from Transvestism to Transvestic Fetishism. This ‘‘The person has acted on these urges, or is markedly distressed
was probably an attempt to disambiguate the term transves- by them.’’ In the present context, this meant that sexual urges to
tism, which was then, as now, sometimes used to denote cross-dress and sexual fantasies of cross-dressing were not
cross-dressing homosexual men (‘‘drag queens’’), and which sufficient for a diagnosis of Transvestic Fetishism; the patient
had historically also been used to denote transsexuals (e.g.,
2
Hamburger, Stürup, & Dahl-Iversen, 1953), before the term I have written about this previously. In Blanchard (2005), I stated,
transsexual became standard for that group. ‘‘The emphasis placed by many writers on the physical properties of
clothing used for cross-dressing (silky textures, striking colors) likely
In my opinion, the name choice of Transvestic Fetishism was
militated against the realization that erotic arousal at the thought of
counter-heuristic. It stresses one frequent feature of transvestism being a woman could arise with no ideas or actions involving women’s
(erotic interest in the material properties of women’s clothing) at apparel at all’’ (p. 441).
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366 Arch Sex Behav (2010) 39:363–372
must either have tried on women’s apparel or else be distressed the DSM-III-R’s diagnostic criteria for transvestism and
by his desires to do so. Thus, an adolescent male, who had gender identity disorders, which presuppose that gender
unconflicted sexual desires to cross-dress but who lived at close dysphoria and fetishistic reactions are mutually exclu-
quarters with his family and had literally no opportunity to sive (p. 426).
satisfy these desires, could not be diagnosed with Transvestic
In the discussion section of their article, Blanchard and
Fetishism.
Clemmensen (1988) argued that the overlap of heterosexual
gender dysphoria and fetishistic cross-dressing was more likely
DSM-IV
to have been underestimated from their data than overestimated.
The recognition that gender dysphoria and erotic arousal to
In this version of the DSM, cross-dressing behavior was
cross-dressing are not mutually exclusive was an important
moved from Criterion B to Criterion A, where it became
step forward for DSM-IV. The implementation of the changes
simply another sign or symptom or transvestism. Criterion B
to the diagnostic criteria and to the text was awkward and
was now purely a distress/impairment criterion, written in
confusing, however. The text for Transvestic Fetishism states:
precisely the same language for all the paraphilias: ‘‘The
fantasies, sexual urges, or behaviors cause clinically signif- Transvestic Fetishism is not diagnosed when cross-
icant distress or impairment in social, occupational, or other dressing occurs exclusively during the course of Gen-
important areas of functioning.’’ der Identity Disorder. (p. 531)
The foregoing change produced the absurd situation that a
The text for Gender Identity Disorder states:
man could not be diagnosed with Transvestic Fetishism unless
he was distressed or impaired by being a transvestite (Zucker Males with a presentation that meets full criteria for
& Blanchard, 1997). As I will show later, this problem could Gender Identity Disorder as well as Transvestic Fetish-
be solved without re-writing the diagnostic criteria at all, ism should be given both diagnoses. (p. 536)
simply by re-naming the syndrome Transvestic Disorder—
Suppose that an adolescent male meets full criteria for Gender
getting rid of an inapt name in the process—and by making a
Identity Disorder before he begins to fantasize about cross-
distinction between ascertaining transvestism (Criterion A)
dressing and before his first episode of fetishistic cross-dressing.
and diagnosing a Transvestic Disorder (Criterion B).
His cross-dressing, once initiated, is highly erotic and often
In DSM-IV, gender dysphoria/transsexualism is no longer
culminates in masturbation to orgasm; however, its temporal
an exclusionary criterion for the diagnosis. The diagnostic
course lies entirely within that of the Gender Identity Disorder.
criteria now offer the specifier With Gender Dysphoria, which
Should he be diagnosed with Transvestic Fetishism or not? The
should be used ‘‘if the person has persistent discomfort with
text for Gender Identity Disorder suggests yes; the text for
gender role or identity.’’ This amendment to the diagnostic
Transvestic Fetishism suggests no.
criteria was consistent with data showing that gender dys-
The text for Gender Identity Disorder also contains the
phoria and erotic arousal to cross-dressing are not mutually
following statement:
exclusive. This had been demonstrated in a study by Blanchard
and Clemmensen (1988). The abstract of their article states: If gender dysphoria is present in an individual with
Transvestic Fetishism but full criteria for Gender
This study sought to determine the proportion of adult,
Identity Disorder are not met, the specifier With Gender
male, heterosexual cross-dressers who acknowledge
Dysphoria can be used (pp. 536–537).
both gender dysphoria and at least occasional fetishistic
response to cross-dressing. Subjects were 193 outpa- There are two questionable points about this recommen-
tients of the gender identity clinic or behavioral sexology dation. First, it is not clear how someone could exhibit gender
department of a psychiatric teaching hospital. Ques- dysphoria, defined in the Transvestic Fetishism diagnostic
tionnaire items were used to assess subjects’ current le- criteria as ‘‘persistent discomfort with gender role or iden-
vel of gender dysphoria and their recent history of sexual tity,’’ and not meet full diagnostic criteria for Gender Identity
response to cross-dressing. Subjects who reported higher Disorder. Second, even if the patient somehow failed to meet
levels of gender dysphoria tended to report lower fre- full diagnostic criteria for Gender Identity Disorder, why not
quencies of sexual arousal with cross-dressing (r = simply use the available diagnosis of Gender Identity Dis-
-.56, p \ .0001) and lower frequencies of masturbation order Not Otherwise Specified?
with cross-dressing (r = -.62, p \ .0001). About half In summary, the use of the specifier With Gender Dysphoria
of even the most strongly gender dysphoric subjects, seems to have been an unnecessarily cumbersome and redun-
however, acknowledged that they still become sexually dant way of doing something that could have been accom-
aroused or masturbate at least occasionally when cross- plished more simply with the addition of a second diagnosis—
dressing. These findings indicate a need for revision in Gender Identity Disorder or Gender Identity Disorder Not
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Arch Sex Behav (2010) 39:363–372 367
Otherwise Specified. As a practical matter, the clinical conse- Table 1 Proposed diagnostic criteria for Transvestic Disorder
quences of gender dysphoria are at least as great as those of A. Over a period of at least 6 months, in a heterosexual male, recurrent,
Transvestic Fetishism, and therefore the presence of gender intense sexually arousing fantasies, sexual urges, or behaviors
dysphoria would better have been highlighted by a separate involving cross-dressing.
diagnosis rather than by noting its presence with a specifier. B. The fantasies, sexual urges, or behaviors cause clinically significant
The text of DSM-IV specifically mentions the existence of distress or impairment in social, occupational, or other important
areas of functioning.
transvestites who cease to experience sexual arousal in
Specify if:
association with cross-dressing; however, it no longer says
With Fetishism (Sexually Aroused by Fabrics, Materials, or
anything about whether their diagnosis should be altered or
Garments)
to what it should be altered:
With Autogynephilia (Sexually Aroused by Thought or Image of
In some individuals, the motivation for cross-dressing Self as Female)
may change over time, temporarily or permanently, with
sexual arousal in response to the cross-dressing dimin- diagnostic criteria, and the following pages explain and justify
ishing or disappearing. In such instances, the cross- the altered features.
dressing becomes an antidote to anxiety or depression or The most obvious difference between the proposed criteria
contributes to a sense of peace and calm. (p. 531) and those used in DSM-IV and DSM-IV-TR is the replacement of
the specifier ‘‘With Gender Dysphoria’’ by the specifiers ‘‘With
In the foregoing passage, the DSM-IV introduced the Fetishism’’ and ‘‘With Autogynephilia.’’ The term autogyne-
notion (which was not explicitly stated in earlier versions) philia (Blanchard, 1989a) denotes a male’s propensity to be
that the motivation for cross-dressing may change over time. erotically aroused by the thought or image of himself as a female.
This seemingly simple descriptive statement actually con- The frequent co-occurrence of fetishism and transvestism was
tains a lot of inference. How does one know that the funda- reported by Wilson and Gosselin (1980). The frequent co-
mental motivation for cross-dressing has changed in these occurrence of autogynephilia and transvestism was reported by
cases? It is, after all, the same people, doing the same thing. Blanchard (1991).
There is no obvious and objective change in incentives, as in
the case of an amateur athlete becoming a paid professional. Commentary on the Proposed Criteria
It is possible that the diminution in ‘‘sexual arousal’’ (which,
in context, probably means a decrease in spontaneous penile Renaming the Diagnosis
tumescence or in the patient’s likelihood of masturbating
while cross-dressed) simply reflects a developmental dif- The first problem with the DSM-IV-TR diagnostic criteria—
ference in the manifestation of transvestism. erotic cross-dressing can be labeled transvestism only if the
practitioner is distressed or impaired by it—can be solved
simply by changing the name of the diagnosis from Transvestic
DSM-IV-TR Fetishism to Transvestic Disorder. Such a name change is con-
sistent with my general proposal to distinguish between para-
The DSM-IV-TR diagnostic criteria for Transvestic Fetish- philias and paraphilic disorders. On this view, a paraphilia is
ism are identical to the DSM-IV criteria. Therefore the fol- any powerful and persistent sexual interest other than sexual
lowing problems remain: interest in copulatory or precopulatory behavior with pheno-
typically normal, consenting adult human partners (Cantor,
1. A man cannot be identified as a transvestite—however
Blanchard, & Barbaree, 2009). A paraphilic disorder is a par-
much he cross-dresses and however sexually exciting
aphilia that causes impairment or distress. One would ascertain
that is to him—unless he is unhappy about this activity or
a paraphilia (determine whether it is present or absent according
impaired by it.
to common signs or symptoms) but diagnose a paraphilic dis-
2. There is no clear diagnostic guidance regarding patients
order (determine whether the paraphilia is distressing the pa-
whose sexual response to cross-dressing diminishes or
tient or impairing his psychosocial functioning). In my propo-
disappears while their frequency of cross-dressing
sal for Transvestic Disorder, Criterion A is an ascertainment
remains the same or grows even higher.
criterion that identifies the patient as transvestic according to
3. The one available specifier (With Gender Dysphoria) is
traditional indicators of transvestism, and Criterion B is a diag-
unnecessary and confusing, whereas other specifiers of
nostic criterion that classifies the patient’s condition as a psy-
potential usefulness are lacking.
chiatric disorder on the grounds of distress or impairment.
The remainder of this report concerns my proposed solutions The immediate consequence of re-naming the diagnosis is
to these problems. Table 1 presents my proposed revision of the that the patient does not have to be subjectively distressed or
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368 Arch Sex Behav (2010) 39:363–372
objectively impaired by his transvestism to be identified as a seem quite similar to simple fetishists in their preference for
transvestite; he simply has to manifest the syndrome of re- very specific garments (e.g., white panties) and report no con-
peated dressing in women’s apparel with sexual excitement scious thoughts of themselves as female even while dressed in
(Criterion A). An ego-syntonic, well-adjusted transvestite multiple pieces of female underwear (panties, brassieres, and
could be classified as a transvestite for research or descriptive stockings). Some men of this type have particular rituals (e.g.,
purposes without being diagnosed with a disorder. This elim- tearing their women’s undergarments to shreds at some point
inates the paradox implied by a literal reading of the DSM- during their masturbatory routine) that make them seem much
IV-TR criteria for Transvestic Fetishism, according to which more similar to fetishists than to other transvestites. Other
a man cannot be a transvestite unless he is upset or handi- transvestites, whom I have called autogynephiles, are most
capped by being a transvestite. aroused by the thought or image of themselves as women. For
these men, the material properties of women’s garments may
Duration of Signs and Symptoms seem secondary. The most exciting act is appearing to oneself
and to others as a woman. There are many variations on this
I have not suggested any alteration of the qualifying phrase, theme. A very common one is forced feminization, a fantasy
‘‘over a period of at least 6 months,’’ but I will note that it scenario in which a man is coerced into wearing feminine attire
might be better applied to Criterion B than to Criterion A. by a dominant woman or group of women (e.g., an improbably
Penile erection and masturbation in connection with the act or motivated college sorority). This scenario is very common
fantasy of changing into women’s apparel rarely or never in fiction written by transvestites for transvestites (Beigel &
occur as transient phenomena in adult men. There does not, Feldman, 1963; Buhrich & McConaghy, 1976; see also Veale,
therefore, seem to be any particular need to stress the duration Clarke, & Lomax, 2008).3 In this fiction, the (male) protagonist
of signs and symptoms in Criterion A. Some duration con- inevitably turns out to make an astonishingly beautiful and
dition might actually make more sense in Criterion B, be- convincing woman as soon as his wig, make-up, and so on are in
cause the distress occasioned by transvestism could fluctuate place, and he may live happily thereafter in a romantic rela-
according to circumstances (whether the patient is married or tionship with the woman who precipitated this discovery.
single, for example), and according to levels of self-accep- As a practical matter, the autogynephilic type seems to have a
tance that could change as the patient ages. higher risk of developing gender dysphoria. There is, at present,
no way besides specifiers to capture the distinction between
‘‘Post-Erotic’’ Transvestites notably fetishistic and notably autogynephilic transvestites. This
cannot be done simply by assigning patients a second paraphilic
My proposed approach to the second problem with DSM-IV- diagnosis, because there is no specific DSM diagnosis of auto-
TR—the diagnosis of patients who report that sexual res- gynephilia. Therefore my solution to the third problem with the
ponding to cross-dressing has disappeared—is to deal with DSM-IV-TR diagnosis of transvestism—the lack of meaningful
this in the text rather than in the diagnostic criteria. I suggest specifiers—is to add the specifiers ‘‘With Fetishism’’ and ‘‘With
that patients who have been clearly ascertained as transvestic Autogynephilia.’’ The usefulness of these specifiers is evaluated
retain that label whether or not they report that cross-dressing in the next section of this report.
continues to be accompanied by penile erection or subjective
feelings identifiable as sexual excitement.
Empirical Study of the Proposed Specifiers: Frequency of
Specifiers
Use and Relation to Gender Dysphoria
As I have previously indicated, I do not see any need for the
I have, in the past, conducted several studies on the relations
DSM-IV-TR specifier ‘‘With Gender Dysphoria.’’ If the pa-
among transvestism, fetishism, autogynephilia, and gender dys-
tient has gender dysphoria in addition to Transvestic Disorder,
phoria (e.g., Blanchard, 1991, 1993). Relevant research has also
he can simply receive the additional diagnosis of Gender
been conducted by other investigators (e.g., Wilson & Gosselin,
Identity Disorder or Gender Identity Disorder Not Otherwise
1980). None of the prior studies, however, bears directly on the
Specified (or their equivalents in DSM-V). The clinical con-
potential frequency of the use of both proposed specifiers
sequences of gender dysphoria are at least as great as those
(fetishism and autogynephilia) in an ascertained sample of
of transvestic disorder, and therefore the presence of gender
dysphoria would better be highlighted by a separate diagnosis.
3
There is, on the other hand, a need to distinguish different A great deal of transvestite fiction can be accessed over the Internet. It can
be found by using search strings like ‘‘transvestite fiction’’ or ‘‘transgender
types of transvestism according to the foci of the patient’s erotic
fiction’’ with an Internet search engine. Much of this material, however, is
interest. Transvestites vary greatly in their overt behavior and in not free. An exception is the free site http://www.fictionmania.tv/index.
their mental content during sessions of cross-dressing. Some html, which contains many thousands of elaborately catalogued stories.
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Arch Sex Behav (2010) 39:363–372 369
transvestites, and none of them has examined the relations of first felt sexually attracted to males?’’ ‘‘In your sexual fan-
fetishism and autogynephilia to gender dysphoria within an tasies, are females age 17–40 always, or almost always, in-
ascertained sample of transvestites. I therefore carried out a volved?’’ Patients who obtained scores less than 10 were
secondary analysis of a pre-existing dataset to investigate the classified as heterosexual and those with scores greater than
utility of the proposed diagnostic specifiers for Transvestic or equal to 10 were classified as homosexual.
Disorder.
Transvestism This was assessed with the Cross-Gender
Method Fetishism Scale (Blanchard, 1985). Its items include the fol-
lowing: ‘‘Has there ever been a period in your life of one year (or
Subjects longer) during which you always or usually masturbated if you
put on female underwear or clothing?’’ ‘‘Have you ever felt
The pool of potential subjects consisted of 427 adult male sexually aroused when putting on women’s perfume or make-
outpatients who reported histories of dressing in women’s up, or when shaving your legs?’’ A subject was classified as
garments, of feeling like women, or both. This group of pa- transvestic if he endorsed any item on this scale.
tients was originally studied by Blanchard (1992). The raw
data from Blanchard (1992) had been archived in a separate Autogynephilia This trait was measured with the Core Auto-
computer file, and they were therefore a convenient dataset gynephilia Scale (1989b). The scale’s items include these:
for the present purpose. ‘‘Have you ever become sexually aroused while picturing
These patients had presented from 1980 to 1990 at one of yourself having a nude female body or with certain features of
two departments of the Clarke Institute of Psychiatry (now the nude female form?’’ ‘‘Have you ever been sexually aroused
the Centre for Addiction and Mental Health, Toronto, On- by the thought of being a woman?’’ A patient was classified as
tario, Canada): the Research Section of Behavioural Sexol- autogynephilic if he obtained a score of three or higher on this
ogy (now the Kurt Freund Laboratory) or the Gender Identity instrument.
Clinic for adults. Because the data analyzed by Blanchard
(1992) and reanalyzed here are from questionnaires, all these Fetishism As in Blanchard (1991), a patient was classified
patients were necessarily literate in English. as fetishistic if he responded positively to the single ques-
In 392 cases (92% of the sample), the patient’s presenting tionnaire item, ‘‘Do you think that certain inanimate objects
complaint was gender dysphoria or transvestism, and the ques- (velvet, silk, leather, rubber, shoes, female underwear, etc.)
tionnaire materials were administered in the course of assessing have a stronger sexual attraction for you than for most other
these conditions. For most of the remaining 35 cases, the recorded people?’’
presenting complaint (usually the most serious condition present)
was masochism, sadism, fetishism, or the courtship disorder Desire for Sex Reassignment Surgery The patient was clas-
cluster (voyeurism, exhibitionism, toucheurism–frotteurism, and sified on this variable according to the single questionnaire item,
preferential rape). ‘‘Have you ever wanted to have an operation to change you
physically into a woman?’’ Patients who endorsed the response-
Materials option ‘‘Unsure’’ were grouped with those who responded
‘‘No.’’
The questionnaire measures in this reanalysis assessed sexual
orientation, transvestism, autogynephilia, fetishism, the desire Female Gender Identity This attribute was assessed with the
for sex reassignment surgery, and feminine gender identity. All single questionnaire item, ‘‘Have you ever felt like a woman?’’
of these measures, including those that are multi-item scales, Patients were scored positively if they endorsed the response-
were dichotomized for this study. As a strategy to avoid ‘‘over- option, ‘‘At all times and for at least one year.’’ Patients were
fitting’’ the data, I used the same cutting score for the variables, scored negatively if they indicated that they had never experi-
sexual orientation, transvestism, autogynephilia, and fetishism, enced such feelings or that they experienced them intermittently.
as I had used in an earlier analysis (Blanchard, 1991). For the
same reason, I tried only one way of dichotomizing the items for
surgery and female identity, rather than making any attempt to Results
adjust such recoding to obtain the strongest or the cleanest
results. Nine of the 427 patients were missing data on sexual orientation.
Of the remainder, 292 were classified as heterosexual, and 126
Sexual Orientation This was assessed with the Modified as homosexual. A history of transvestism was admitted by 247
Androphilia-Gynephilia Index (Blanchard, 1985). Sample (85%) of the heterosexual patients and denied by the other
items from this scale are: ‘‘About how old were you when you 45 (15%). There were no obvious demographic differences
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370 Arch Sex Behav (2010) 39:363–372
Table 2 Numbers and percentages of transvestites who acknowledged

Table 4 Prediction of constant female identity
fetishism or autogynephilia
B SE Wald df p eB
Fetishism Total
Denied Admitted Autogynephilia 1.438 .407 12.483 1 .00041 4.211
Fetishism -1.905 .307 38.628 1 .00000 .149
Autogynephilia Constant -.146 .382 .146 1 .70258 .864
Denied
Count 19 28 47
% of total 7.7% 11.3% 19.0%
Admitted
These results show that transvestic patients who acknowl-
Count 79 121 200
edged autogynephilia had almost five times higher odds of report-
% of total 32.0% 49.0% 81.0%
ing past or current desires for sex reassignment than transvestic
Total
patients who denied autogynephilia. The opposite result was
Count 98 149 247 found for fetishism, that is, transvestites who reported fetishism
% of total 39.7% 60.3% 100.0% were less likely to report a desire for sex reassignment. It is
noteworthy that these predictors were independent to a large
extent. Both were highly significant when the other was con-
between the heterosexual patients who admitted and those who trolled for.
denied transvestism. The mean age of the admitters was 33.38 The criterion variable in the second analysis was whether
years (SD = 9.53), and that of the deniers was 33.22 years the patient had an unwavering female identity. The predictor
(SD = 9.10), t(290) = 0.11, ns. The mean education of the variables were the same as in the first analysis, and the equation
admitters was 5.19 (SD = 1.23), where ‘‘5’’ equaled ‘‘at least 12 was built in the same way. The results are shown in Table 4.
grades completed but no university,’’ and that of the deniers was The results were similar to those from the first analysis.
4.93 (SD = 1.12), where ‘‘4’’ equaled ‘‘more than 8 grades Transvestic patients who acknowledged autogynephilia had
completed but less than 12,’’ t(290) = 1.29, ns. over four times higher odds of reporting unwavering female
The numbers of admittedly transvestic patients who ac- identities than transvestic patients who denied autogyne-
knowledged histories of fetishism, autogynephilia, both, or philia. Transvestites who reported fetishism were less likely
neither are shown in Table 2. There is nothing in these results to report constant female identities. Fetishism was a stronger
to suggest that either of the proposed diagnostic specifiers predictor than autogynephilia even though it was assessed
should be eliminated. Only 7.7% of cases denied both fetish- with a single questionnaire item.
ism and autogynephilia. Almost half of this sample (49%)
acknowledged histories of both fetishism and autogynephilia. Discussion
Two binary logistic regression analyses were used to
investigate the potential clinical significance of these specifi- There is no doubt that questionnaire data canvassing gender
ers. These were carried out on 244 patients, because 3 patients identity, desires for sex reassignment, fetishism, and so on are
were missing the questionnaire section pertaining to gender strongly influenced by many extraneous factors, for example,
dysphoria. patients’ desires to present themselves in a favorable light for
The criterion variable in the first analysis was whether the obtaining sex hormones or reassignment surgery, embarrass-
patient had ever wanted sex reassignment surgery. The two ment regarding unusual or bizarre sexual practices, and mis-
predictors were the patient’s self-reported history of auto- understanding or incomprehension of questionnaire items. On
gynephilia and his self-reported history of fetishism. Both the other hand, the results obtained with these crude and
predictors were entered directly into the equation. The results obvious measures were quite strong, and they did clearly
are shown in Table 3. suggest that the addition of the proposed specifiers to the
diagnosis of transvestic disorder could provide clinically
meaningful information as well as data useful for research.
Table 3 Prediction of the desire for sex reassignment Acknowledgments The author is a member of the DSM-V Work-
group on Sexual and Gender Identity Disorders. He wishes to thank his
B SE Wald df p eB colleagues Maxine Petersen, Robert Dickey, and Kenneth J. Zucker for
their stimulating conversations, over many years, about cross-gender
Autogynephilia 1.596 .367 18.915 1 .00001 4.933 behavior and ideation in nonhomosexual biological male patients.
Fetishism -1.467 .366 16.102 1 .00006 .231 Reprinted with permission from the Diagnostic and Statistical Manual
of Mental Disorders V Workgroup Reports (Copyright 2009). American
Constant .741 .380 3.799 1 .05127 2.099
Psychiatric Association.
123
Arch Sex Behav (2010) 39:363–372 371
Appendix References
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A. Recurrent and persistent cross-dressing by a hetero- American Psychiatric Association. (1987). Diagnostic and statistical
sexual male. manual of mental disorders (3rd ed., revised). Washington, DC:
Author.
B. Use of cross-dressing for the purpose of sexual excite- American Psychiatric Association. (1994). Diagnostic and statistical
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C. Intense frustration when the cross-dressing is interfered American Psychiatric Association. (2000). Diagnostic and statistical
with. manual of mental disorders (4th ed., text revision). Washington,
DC: Author.
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in fiction, research, and reality. In H. G. Beigel (Ed.), Advances in
sex research (pp. 198–209). New York: Harper & Row.
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III-R (1987) Press.
Blanchard, R. (1985). Research methods for the typological study of
A. Over a period of at least six months, in a heterosexual male, gender disorders in males. In B. W. Steiner (Ed.), Gender dysphoria:
recurrent intense sexual urges and sexually arousing fan- Development, research, management (pp. 227–257). New York:
Plenum Press.
tasies involving cross-dressing. Blanchard, R. (1989a). The classification and labeling of nonhomosex-
B. The person has acted on these urges, or is markedly ual gender dysphorias. Archives of Sexual Behavior, 18, 315–334.
distressed by them. Blanchard, R. (1989b). The concept of autogynephilia and the typology
C. Does not meet the criteria for Gender Identity Disorder of male gender dysphoria. Journal of Nervous and Mental Disease,
177, 616–623.
of Adolescence or Adulthood, Nontranssexual Type, or Blanchard, R. (1991). Clinical observations and systematic studies of
Transsexualism. autogynephilia. Journal of Sex & Marital Therapy, 17, 235–251.
Blanchard, R. (1992). Nonmonotonic relation of autogynephilia and
heterosexual attraction. Journal of Abnormal Psychology, 101,
271–276.
Diagnostic Criteria for Transvestic Fetishism in DSM-IV
Blanchard, R. (1993). Varieties of autogynephilia and their relationship
(1994) to gender dysphoria. Archives of Sexual Behavior, 22, 241–251.
Blanchard, R. (2005). Early history of the concept of autogynephilia.
A. Over a period of at least 6 months, in a heterosexual Archives of Sexual Behavior, 34, 439–446.
male, recurrent, intense sexually arousing fantasies, Blanchard, R., & Clemmensen, L. H. (1988). A test of the DSM-III-R’s
sexual urges, or behaviors involving cross-dressing. implicit assumption that fetishistic arousal and gender dysphoria
B. The fantasies, sexual urges, or behaviors cause clinically are mutually exclusive. Journal of Sex Research, 25, 426–432.
Blanchard, R., Racansky, I. G., & Steiner, B. W. (1986). Phallometric
significant distress or impairment in social, occupational, detection of fetishistic arousal in heterosexual male cross-dressers.
or other important areas of functioning. Journal of Sex Research, 22, 452–462.
Buhrich, N. (1978). Motivation for cross-dressing in heterosexual
Specify if: transvestism. Acta Psychiatrica Scandinavica, 57, 145–152.
Buhrich, N., & Beaumont, T. (1981). Comparison of transvestism in
With Gender Dysphoria: if the person has persistent Australia and America. Archives of Sexual Behavior, 10, 269–279.
discomfort with gender role or identity Buhrich, N., & McConaghy, N. (1976). Transvestite fiction. Journal of
Nervous and Mental Disease, 163, 420–427.
Buhrich, N., & McConaghy, N. (1977a). The clinical syndromes of
femmiphilic transvestism. Archives of Sexual Behavior, 6, 397–
Diagnostic Criteria for Transvestic Fetishism 412.
in DSM-IV-TR (2000) Buhrich, N., & McConaghy, N. (1977b). The discrete syndromes of
transvestism and transsexualism. Archives of Sexual Behavior, 6,
A. Over a period of at least 6 months, in a heterosexual male, 483–495.
recurrent, intense sexually arousing fantasies, sexual urges, Cantor, J. M., Blanchard, R., & Barbaree, H. E. (2009). Sexual disorders.
or behaviors involving cross-dressing. In P. H. Blaney & T. Millon (Eds.), Oxford textbook of psycho-
pathology (2nd ed., pp. 527–548). New York: Oxford University
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significant distress or impairment in social, occupational, Croughan, J. L., Saghir, M., Cohen, R., & Robins, E. (1981). A
or other important areas of functioning. comparison of treated and untreated male cross-dressers. Archives
Specify if: Docter, R. F., & Prince, V. (1997). Transvestism: A survey of 1032
cross-dressers. Archives of Sexual Behavior, 26, 589–605.
With Gender Dysphoria: if the person has persistent Freund, K., Seto, M. C., & Kuban, M. (1996). Two types of fetishism.
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Hamburger, C., Stürup, G. K., & Dahl-Iversen, E. (1953). Transvestism: Wilson, J. R., Kuehn, R. E., & Beach, F. A. (1963). Modification in the
Hormonal, psychiatric and surgical treatment. Journal of the Amer- sexual behavior of male rats produced by changing the stimulus
ican Medical Association, 152, 391–396. female. Journal of Comparative and Physiological Psychology,
Långström, N., & Zucker, K. J. (2005). Transvestic fetishism in the 56, 636–644.
general population: Prevalence and correlates. Journal of Sex and Wise, T. N., & Meyer, J. K. (1980). The border area between
Marital Therapy, 31, 87–95. transvestism and gender dysphoria: Transvestitic applicants for
Ovesey, L., & Person, E. (1976). Transvestism: A disorder of the sense sex reassignment. Archives of Sexual Behavior, 9, 327–342.
of self. International Journal of Psychoanalytic Psychotherapy, 5, Zucker, K. J., & Blanchard, R. (1997). Transvestic fetishism: Psycho-
219–235. pathology and theory. In D. R. Laws & W. O’Donohue (Eds.),
Person, E., & Ovesey, L. (1978). Transvestism: New perspectives. Sexual deviance: Theory, assessment, and treatment (pp. 253–
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DOI 10.1007/s10508-009-9552-0
ORIGINAL PAPER
The DSM Diagnostic Criteria for Paraphilia Not Otherwise

Specified
Martin P. Kafka

Abstract The category of ‘‘Not Otherwise Specified’’ (NOS) Introduction

for DSM-based psychiatric diagnosis has typically retained diag-
noses whose rarity, empirical criterion validation or symptomatic Prior to an informed discussion of the residual category for
expression has been insufficient to be codified. This article re- paraphilic disorders, Paraphilia Not Otherwise Specified (PA-
views the literature on Telephone Scatologia, Necrophilia, Zoo- NOS), it is important to briefly review the diagnostic criteria
philia, Urophilia, Coprophilia, and Partialism. Based on extant for a categorical diagnosis of paraphilic disorders as well as the
data, no changes are suggested except for the status of Partialism. types of conditions reserved for the NOS designation.
Partialism, sexual arousal characterized by ‘‘an exclusive focus The diagnostic criteria for paraphilic disorders have been mod-
on part of the body,’’ had historically been subsumed as a type of ified during the publication of the Diagnostic and Statistical Man-
Fetishism until the advent of DSM-III-R. The rationale for con- uals of the American Psychiatric Association. In the latest edition,
sidering the removal of Partialism from Paraphilia NOS and its DSM-IV-TR (American Psychiatric Association, 2000), a para-
reintegration as a specifier for Fetishism is discussed here and in a philic disorder must meet two essential criteria. The essential
companion review on the DSM diagnostic criteria for fetishism features of a Paraphilia are recurrent, intense sexually arousing
(Kafka, 2009). In the DSM-IV and DSM-IV-TR, the essential fantasies, sexual urges or behaviors generally involving (1) non-
features of a Paraphilia are recurrent, intense sexually arousing human objects, (2) the suffering or humiliation of oneself or one’s
fantasies, sexual urges or behaviors generally involving nonhu- partner, or (3) children or other nonconsenting persons that occur
man objects, the suffering or humiliation of oneself or one’s part- over a period of at least 6 months (Criterion A). The diagnosis is
ner, or children or other nonconsenting persons that occur over a made if the behavior, sexual urges, or fantasies cause clinically
period of at least 6 months (Criterion A). Given consideration for significant distress or impairment in social, occupational, or other
the erotic focus of Partialism and Autoerotic Asphyxia, amending important areas of functioning (Criterion B).
the operational criteria for Paraphilia should be considered to in- For paraphilic disorders typically associated with sexual
clude an atypical focus involving human subjects (self or others). offending, additional caveats are included: For Pedophilia,
Voyeurism, Exhibitionism, and Frotteurism, the diagnosis is
Keywords DSM-V Coprophilia Necrophilia made if the person has acted on those urges or the urges or
Partialism Telephone scatologia Urophilia Zoophilia sexual fantasies cause marked distress or interpersonal dif-
ficulty. For Sexual Sadism, the diagnosis is made if the person
has acted on these urges with a nonconsenting person or the
urges, sexual fantasies or behaviors cause marked distress or
interpersonal difficulties.
In the fourth edition of the DSM (American Psychiatric
Association, 1994) and well as in the text revision of DSM-IV
(American Psychiatric Association, 2000, p. 4), the NOS cate-
M. P. Kafka (&)
gories are described as applicable to four situations: (1) The
Belmont, MA 02478, USA presentation conforms to the general guidelines for a mental
e-mail: [email protected] disorder in the diagnostic class, but the symptomatic picture
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374 Arch Sex Behav (2010) 39:373–376
does not meet the criteria for any of the specific disorders. This Telephone Scatologia
would occur either when the symptoms are below the diagnostic
threshold for one of the specific disorders or when there is an Telephone Scatologia, a paraphilic disorder characterized by
atypical or mixed presentation; (2) the presentation conforms to repetitive telephone calls to unsuspecting victims during which
a symptom pattern that has not been included in the DSM-IV they are exposed to covert or overt sexual or obscene content,
classification but causes clinically significant distress or impair- has been recognized in association with other paraphilic disor-
ment. Research criteria for some of these symptoms patterns ders, most notably Exhibitionism (Abel, Becker, Cunningham-
have been included in Appendix B (‘‘Criteria Sets and Axes Rathner, Mittelman, & Rouleau, 1988) and Voyeurism (Brad-
Provided for Further Study’’), in which case a page reference to ford, Boulet, & Pawlak, 1992). Abel et al.’s sample of 561 non-
the suggested research criteria set in Appendix B is provided; (3) incarcerated paraphiliacs included 19 subjects (3.3% of the
there is uncertainty about etiology (i.e., whether the disorder is sample) who acknowledged telephone scatologia and Bradford
due to a general medical condition, is substance-induced or is et al.’s sample of 37 men (8.3%) were extracted from a non-
primary); and (4) there is insufficient opportunity for complete incarcerated sample of 443 men being evaluated at a specialized
data collection (e.g., in emergency situations) or inconsistent or forensic center.
contradictory information, but there is enough information to Price, Kafka, Commons, Gutheil, and Simpson (2002) exam-
place it within a particular diagnostic class (e.g., the clinician ined an outpatient sample of 206 men with paraphilias and para-
determines that the individual has psychotic symptoms but does philia-related disorders (Kafka & Hennen, 1999) and identified
not have enough information to diagnose a specific Psychotic 20 men (9.7% of the sample) with a lifetime diagnosis of Tele-
Disorder). phone Scatologia. They reported a significant comorbidity be-
In the specific case of Paraphilic Disorders, there are no tween Telephone Scatologia and Voyeurism, compulsive mas-
Appendix B Criteria Sets provided for further study. In DSM-IV turbation, telephone sex dependence, and a trend association with
and in DSM-IV-TR, the Paraphilia NOS category (diagnostic Exhibitionism (p = 06). The Telephone Scatologia subgroup
code 302.9) states: ‘‘This category is included for coding Para- had a greater number of lifetime paraphilias and paraphilia-
philias that do not meet the criteria for any of the specific catego- related disorders in comparison with other paraphiliacs. The
ries. Examples include, but are not limited to, telephone scatolo- particular finding of multiple paraphilias in men with Telephone
gia (obscene phone calls), necrophilia (corpses), partialism (ex- Scatologia was also reported by Abel et al. (1988). Although this
clusive focus on parts of the body), zoophilia (animals), copro- paper does add to the clinical literature on Telephone Scatologia, I
philia (feces), klismaphilia (enemas), and urophilia (urine)’’ find insufficient justification to remove telephone scatologia from
(American Psychiatric Association, 1994, p. 532). the Paraphilia NOS category.
Methodology Necrophilia
I performed an Internet-based literature search using the terms Apart from the sample accrued by Rosman and Resnick (1989;
‘‘Paraphilia Not Otherwise Specified,’’ ‘‘telephone scatologia,’’ 122 cases: 88 from the world literature and 34 unpublished
‘‘necrophilia,’’ ‘‘partialism,’’ ‘‘zoophilia,’’ ‘‘bestiality,’’ ‘‘copro- cases), there are no new substantial data on Necrophilia. In their
philia,’’ ‘‘coprolagnia,’’ ‘‘klismaphilia,’’ ‘‘urophilia,’’ ‘‘urolagnia,’’ review, Rosman and Resnick noted that the primary motivation
and ‘‘undinism,’’ utilizing both PubMed (1948–2008) and Psyc- associated with Necrophilia was the ‘‘possession of an unre-
INFO (1872–2008) databases. Inasmuch as DSM-IV was pub- sisting and unrejecting partner.’’ Necrophilia could be considered
lished in 1994 and its revision was published in 2000 without any as a fetish variant as the sexualized object of desire is ‘‘nonliving’’
designated changes in the status of Paraphilia NOS disorders, I but, in my opinion, there are insufficient data to empirically sup-
emphasized empirical data published since 1990, primarily in the port this change to include Necrophilia as a subtype of Fetishism.
English language with sample sizes of more than 20 subjects. I Necrophilia can be accompanied by ‘‘sadistic acts’’ and sexually
reviewed contemporary sexology book chapters, the Internet, and motivated murder, certainly not behaviors associated with Fetish-
other primary sources whenever possible to search for other para- ism as it has been currently defined. Rosman and Resnick also
philic disorders that might now qualify as distinct paraphilic diag- reported that 57% of their sample were employed in a profession
nosis based on more empirical and clinical data. In relevant pub- that gave them access to dead bodies (e.g., morgue attendant,
lications, I reviewed referenced articles as well as those that did not hospital workers, cemetery employee).
appear during a computerized search. I reviewed articles and books Clearly, Necrophilia is a very dangerous paraphilic affliction
through October 2008. This review does not include new data on but the paucity of systematically reported data and the rarity of
autoerotic asphyxia (hypoxyphilia) or paraphilic rapism (para- this important disorder are limitations that, in my opinion, will
philic coercive disorder). maintain Necrophilia as a Paraphilia NOS disorder for DSM-V.
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Arch Sex Behav (2010) 39:373–376 375
Zoophilia non-clinical manifestations of a normal spectrum of eroticization

or clinical disorders causing significant interpersonal difficulties.
There are several sources of new data regarding Zoophilia, Partialism as an entity distinct from Fetishism was endorsed
recurrent intense sexual fantasies, urges and sexual activities by Gebhard, Gagnon, Pomeroy, and Christenson (1965). In con-
with non-human animals. In addition, there is an excellent contemporary psychiatry, Partialism was separated from Fetishism
temporary review of this paraphilia (Milner, Dopke, & Crouch, as a distinct paraphilic category with the advent of DSM-III-R
2008). Zoophilia has been noted historically since biblical times (American Psychiatric Association, 1987). I have discussed Par-
(Taylor, 1996). The most recent data regarding zoophilia have tialism, its current psychiatric status, recent clinical and com-
been gathered from non-clinical samples, particularly via the munity-based ascertainment data, and its historical relationship
Internet (Beetz, 2000; Miletski, 2000, 2002; Williams & Wein- to Fetishism in greater detail in another review paper on Fetish-
berg,2003). Theseaforementioned samples (Williams and Wein- ism (Kafka, 2009). I will summarize my findings here as well.
berg, n = 114; Miletski, n = 93; Beetz, n = 32) all reported that A contemporary literature review of ‘‘partialism’’ reveals no
men and women who self-identified as zoophiles were drawn to new empirical data retrieved with that search term although the di-
animals out of a desire for affection, a sexual attraction toward, agnosis is mentioned in several texts (Cantor, Blanchard, & Bar-
and a love for animals. Many of the subjects preferred sexual baree, 2009; Davis, 1950; Gebhard et al., 1965; McWilliams,
relations with non-human animals, prompting Miletski to suggest 2006; Milner & Dopke, 1997; Milner et al., 2008).
that Zoophilia is an alternative sexual orientation. Persons who In reviewing the psychiatric literature associated with Fetish-
self-identified as zoophiles made a distinction between them- ism, however, it is noteworthy that in clinical, community sam-
selves and others who used animals as sex objects without emo- ples, and Internet-based surveys, Partialism (search-retrieved as
tional attachment (bestialists) (Miletski, 2000, 2002). In all the ‘‘fetishism’’) and Fetishism overlap significantly. For example,
samples, the most commonly preferred animals were either dogs a male with a single fetish may have multiple fetishes, including
or horses. These data, while extensive, were gathered from non- preferential sexual arousal to both body parts as well non-living
clinical samples. Hence, they affirm that Zoophilia can be ascer- objects (Chalkley & Powell, 1983; Scorolli, Ghirlanda, Enquist,
tained through survey and Internet methodologies but they do not Zattoni, & Jannini, 2007; Weinberg, Williams, & Calhan, 1994).
specifically or systematically report on the qualities of ‘‘clinically In both Weinberg et al.’s sample of homosexual and bisexual
significant distress or impairment in social, occupational or other male foot fetishists (n = 262) derived from the Foot Frater-
important areas of functioning’’ (Criterion B for the diagnosis of a nity, an organization of men who acknowledge sexual arousal
paraphilic disorder). Thus, there are more contemporary data on to feet and objects associated with feet, as well as Scorolli
self-identified zoophiles but I see no justification or advantage for et al.’s Internet-based survey of Yahoo-based fetish interest
changing this clinically uncommon paraphilia from its current groups (estimated n = [5000), there was significant overlap
designation in the Paraphilia NOS category. between men’s expressed fetishistic interest in body parts as
well as non-living objects.
As long as an exclusive sexual interest in a body part is accom-
Coprophilia, Klismaphilia, and Urophilia panied byclinically significant distressorpsychosocial roleimpair-
ment as described by Criterion B for all paraphilic diagnoses, there
I was not able to gather sufficient new data, apart from some seems to be inadequate evidence to maintain a distinction between
isolated case reports on the Paraphilia NOS categories of Cop- Fetishism and Partialism, two diagnostic entities that appear to be
rophilia, Klismaphilia or Urophilia. more on a continuum than as distinct clinical entities. When Par-
tialism was originally cleaved from Fetishism in DSM-III-R, clini-
cally significant impairment was not inherent for a diagnosis of
Partialism paraphilic disorders as is now the case.
For these reasons, I recommend that Partialism be removed
Partialism, a paraphilia NOS characterized as sexually arousing from the Paraphilia NOS category and be included as a subtype
fantasies, urges and sexual behaviors with an ‘‘exclusive focus or specifier for Fetishism (Kafka, 2009).
on part of the (human) body,’’ was historically included as part
of a broader definition of Fetishism by the 19th century French
psychologist Binet (1887), well as the prominent European The Paraphilia Not Otherwise Specified Disorders
sexologists, such as Krafft-Ebing (1965), Ellis (1906), Hirsch- and the Operational Definition of Paraphilia
feld (1956), and Freud (1928). In their seminal writings, all of
the aforementioned sexologists used the terms ‘‘fetish’’ and In reviewing the Paraphilia NOS disorders, it became apparent
‘‘fetishism’’ to specifically describe an intense eroticization of that some of these conditions, such as Partialism and autoerotic
either non-living objects and/or specific body parts that were asphyxia/hypoxyphilia, do not fulfill Criterion A for the oper-
symbolically associated with a person. Fetishes could be either ational definition of a Paraphilia as delineated in DSM-IV and
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376 Arch Sex Behav (2010) 39:373–376
DSM-IV-TR. Partialism, an ‘‘exclusive focus on part of the Chalkley, A. J., & Powell, G. (1983). The clinical description of forty
body,’’ or autoerotic asphyxia (hypoxyphilia), characterized by eight cases of sexual fetishism. British Journal of Psychiatry, 142,
292–295.
intensified ‘‘sexual arousal by oxygen deprivation’’ that is typ- Davis, P. (1950). Miscellaneous sexual perversions. In Sex perversion
ically self-administered (American Psychiatric Association, and the law (Vol. 2, pp. 53–60). New York: Banner Books (Mental
2000), are intrinsically characterized by ‘‘an atypical focus Health Press).
involving human subjects (self or others)’’ (Milner & Dopke, Ellis, H. (1906). Erotic symbolism. In Studies in the psychology of sex
(Vol. II, pp. 1–114). New York: Random House.
1997; Milner et al., 2008). If we are to enhance the specificity Freud, S. (1928). Fetishism. International Journal of Psycho-Analysis,
and boundaries for the DSM-V definition for paraphilic disor- 9, 161–166.
ders by building on its immediately precedent DSM-based Gebhard, P. H., Gagnon, J., Pomeroy, W., & Christenson, C. (1965). Sex
operational definition, then I would recommend that we con- offenders: An analysis of types. New York: Harper & Row.
Hirschfeld, M. (1956). Sexual anomalies: The origins, nature and treatment
sider revising Criterion A for a Paraphilic Disorder to read: The of sexual disorders (2nd ed.). New York: Emerson Books.
essential features of a Paraphilia are recurrent, intense sexually Kafka, M. P. (2009). The DSM diagnostic criteria for fetishism. Ar-
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ing (1) nonhuman objects, (2) the suffering or humiliation of Kafka, M. P., & Hennen, J. (1999). The paraphilia-related disorders: An
empirical investigation of nonparaphilic hypersexuality disorders
oneself or one’s partner, (3) children or other nonconsenting in 206 outpatient males. Journal of Sex and Marital Therapy, 25,
persons, or (4) an atypical focus involving human subjects (self 305–319.
or others) that occur over a period of at least 6 months (Criterion Krafft-Ebing, R. (1965). Psychopathia sexualis. New York: G. P. Putnam’s
A) (my emphasis). Sons (Original work published 1886).
McWilliams, T. (2006). Partialism and the sex offender: The fascination
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on Sexual and Gender Identity Disorders (Chair, Kenneth J. Zucker, Ph.D.). Miletski, H. (2000). Bestiality and zoophilia: An exploratory study.
I wish to acknowledge the valuable input I received from members of my Scandinavian Journal of Sexology, 3, 149–150.
Paraphilias subworkgroup (Ray Blanchard, Richard Krueger, and Niklas Miletski, H. (2002). Understanding bestiality and zoophilia. German-
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Binet, A. (1887). Le fétichisme dans l’amour. Revue Philosophique, 24, Weinberg, M. S., Williams, C. J., & Calhan, C. (1994). Homosexual foot
143–167, 252–274. fetishism. Archives of Sexual Behavior, 23, 611–626.
Bradford, J. M. W., Boulet, J., & Pawlak, A. (1992). The paraphilias: A Williams, C. J., & Weinberg, M. S. (2003). Zoophilia in men: A study of
multiplicity of deviant behaviors. Canadian Journal of Psychiatry, sexual interest in animals. Archives of Sexual Behavior, 32, 523–535.
37, 104–108.
Cantor, J. M., Blanchard, R., & Barbaree, H. (2009). Sexual disorders. In
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DOI 10.1007/s10508-009-9574-7
ORIGINAL PAPER
Hypersexual Disorder: A Proposed Diagnosis for DSM-V

Martin P. Kafka

Abstract Hypersexual Disorder is proposed as a new psy- Introduction

chiatric disorder for consideration in the Sexual Disorders sec-
tion for DSM-V. Historical precedents describing hypersexual Since the publication of the third edition of the Diagnostic and
behaviors as well as the antecedent representations and pro- Statistical Manual of Mental Disorders (DSM-III) (American
posals for inclusion of such a condition in the previous DSM Psychiatric Association, 1980), psychiatric diagnosis has been
manuals are reviewed. Epidemiological as well as clinical evi- criterion-based and atheoretical in defining psychiatric disor-
dence is presented suggesting that non-paraphilic ‘‘excesses’’ ders. At this juncture, we simply do not have the empirical sci-
of sexual behavior (i.e., hypersexual behaviors and disorders) ence to establish causality or pathogenesis for psychiatric dis-
can be accompanied by both clinically significant personal orders (Caine, 2003), including sexual behavior disorders.
distress and social and medical morbidity. The research liter- Despite this limitation, there is well over 100 years of clinical
ature describing comorbid Axis I and Axis II psychiatric dis- history consistently describing excesses of enacted sexual
orders and a purported relationship between Axis I disorders behavior, both paraphilic and normophilic, i.e., sexual activi-
and Hypersexual Disorder is discussed. Based on an extensive ties that conform to the dictates of custom, religion, and law.
review of the literature, Hypersexual Disorder is conceptual- I will review the empirical basis for an atheoretical and cri-
ized as primarily a nonparaphilic sexual desire disorder with terion-based diagnostic categorization for a clinically evident
an impulsivity component. Specific polythetic diagnostic cri- group of sexual behaviors that include: (1) normophilic sexual
teria, as well as behavioral specifiers, are proposed, intended to fantasies, arousal, urges, and behaviors; (2) the duration, fre-
integrate empirically based contributions from various puta- quency, and intensity of these sexual fantasies, urges, and behav-
tive pathophysiological perspectives, including dysregulation iors have become associated with clinically significant personal
of sexual arousal and desire, sexual impulsivity, sexual addic- distress and volitional and social role impairment.
tion, and sexual compulsivity.
Keywords Hypersexuality Sexual desire Literature Search Methodology

Sexual addiction Sexual compulsivity
Paraphilia-related disorder DSM-V I performed an Internet-based literature search primarily utiliz-
ing Medline and PsychInfo databases. Search terms included:
‘‘hypersexual,’’‘‘hypersexuality,’’‘‘sexual addiction,’’‘‘sex
addict,’’‘‘sexual impulsivity,’’‘‘compulsive sexual,’’‘‘compul-
sive sex,’’‘‘sexual compulsion,’’‘‘paraphilia-related disorder,’’
and‘‘excessive sexual.’’I sought articles that included data on
samples greater than 20, whenever possible. In reviewing these
articles, I also sought secondary references, textbooks, and text-
M. P. Kafka (&)
book chapters. This literature search was completed in October
Belmont, MA 02478, USA 2008 but selective additional references that have been sub-
e-mail: [email protected] sequently published have been updated as of April 2009. The
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378 Arch Sex Behav (2010) 39:377–400
diagnostic criteria proposed for Hypersexual Disorder are nostic manuals primarily because of a lack of empirical research
derived from the literature search and review as well as input and consensus validating sexual behavior as a bona fide behav-
from the Paraphilias Working Group and Advisors to the Work- ioral addiction (Wise & Schmidt, 1997).
ing Group. The diagnostic criteria for Hypersexual Disorder In the DSM-IV (American Psychiatric Association, 1994)
proposed in this article were finalized in August 2009. and its text revision, DSM-IV-TR (American Psychiatric Asso-
ciation, 2000), the original DSM-III characterization of these
behaviors was reestablished. Sexual Disorders Not Otherwise
Historical Overview of ‘‘Excessive’’ Sexual Behaviors Specified (302.9) included a condition characterized by:‘‘dis-
tress about a pattern of repeated sexual relationships involving
In Western medicine, excessive sexual behaviors were clini- a succession of lovers who are experienced by the individual
cally documented by diverse clinicians such as Benjamin Rush only as things to be used’’ (p. 582).
(1745–1813), a physician and Founding Father of the United The International Classification of Diseases (ICD), a com-
States (Rush, 1979), as well as the 19th century Western Euro- pendium of medical diagnoses published by the World Health
pean pioneer sexologists Richard von Krafft-Ebing (1940– Organization (2007), also provides a taxonomy of sexual dis-
1902) (Krafft-Ebing, 1965), Havelock Ellis (1859–1939) (Ellis, orders that has been specifically coordinated with the DSM-IV
1905) and Magnus Hirshfeld (1868–1935) (Hirshfeld, 1948). (Frances, Widiger, & Pincus, 1989). The ICD has a provision
These clinicians and investigators each described a panoply for‘‘excessive sexual drive’’(Diagnostic Code F52.7), further
of persistent socially deviant sexual behaviors as well as clini- subdivided into nymphomania (for females) and satyriasis (for
cal examples of males and females whose nonparaphilic (i.e., males). No further description is included.
normophilic) sexual appetite was excessive and maladaptive.
The clinical examples of such appetitive behaviors described
by these investigators were precursors to the 20th century char- DSM-V and Hypersexual Disorder
acterization of protracted promiscuity as Don Juanism (Stoller,
1975) or satyriasis (Allen, 1969) in males and nymphomania I have chosen to establish a proposal for DSM-V diagnostic cri-
(Ellis & Sagarin, 1965) in females. The aforementioned Euro- teria that captures the aforementioned Sexual Disorder NOS des-
pean investigators also described compulsive masturbation as ignations and concurrently is consistent with established medical
a common behavior in their clinical samples. and psychiatric terminology such as current diagnostic descrip-
tors and criteria for other Sexual Disorders. In addition, I am
selecting a scientifically based terminology specifically asso-
The Diagnostic and Statistical Manuals and Excessive ciated with increased or excessive expression of biologically
Normophilic Sexual Behavior Disorders mediated human behaviors or pathological conditions.
When human (and animal) behaviors or biological func-
In organized North American-based psychiatry, the DSM-II tions are‘‘less than’’normal, the Greek language-derived pre-
(American Psychiatric Association, 1968) recognized sexual fix ‘‘hypo-’’ is commonly attached as a descriptor of a path-
deviations as personality disorders but there was no mention ological condition (e.g., hypoactivity, hypothermia, hypo-
of excessive or maladaptive nonparaphilic sexual behavior thyroidism). In contrast‘‘hyper-’’is the prefix consistent with
disorders. By 1980, the DSM-III (American Psychiatric Asso- the notion of‘‘increased’’or‘‘excessive’’behavior associated
ciation, 1980) classified paraphilic disorders as distinct pathol- with discrete pathologies or dysfunctional behavioral outcomes
ogies (Psychosexual Disorders) and a residual diagnostic cat- (e.g., hypersomnia, hyperthyroidism, hyperphagia, hyper-
egory, Psychosexual Disorder Not Otherwise Specified (diag- activity). There is a long history of characterizing behav-
nostic code 302.89) included ‘‘distress about a pattern of iorally enacted excesses of sexual behaviors as ‘‘hypersex-
repeated sexual conquests with a succession of individuals ual’’ (Krafft-Ebing, 1965). Thus, the diagnostic appellation
who exist only as things to be used (Don Juanism and nym- Hypersexual Disorder (Kafka & Hennen, 1999; Kingston &
phomania)’’ (p. 283). Firestone, 2008; Krueger & Kaplan, 2001; Orford, 1978; Reid,
In DSM-III-R (American Psychiatric Association, 1987), Carpenter, Spackman, & Willes, 2008; Stein, Black, Shapira,
the Sexual Disorders Not Otherwise Specified category (diag- & Spitzer, 2001) would be consistent with the aforemen-
nostic code 302.90) added the concept of nonparaphilic sexual tioned clinical characteristics specifically attributed to an
addiction for the first time by stating: distress about a pattern of increase in intensity and frequency of normophilic sexual
repeated sexual conquests or other forms of nonparaphilic sex- behaviors that are associated with significant adverse con-
ual addiction, involving a succession of people who exist only sequences.
as things to be used (p. 296). I choose to introduce this proposed diagnosis and its asso-
The nonparaphilic sexual addiction terminology was discon ciated criteria and terminology at the beginning of this review
tinued in more recent American Psychiatric Association diag- to afford a uniform narrative for the reader. In addition, in a
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Arch Sex Behav (2010) 39:377–400 379
Table 1 Proposed diagnostic criteria for Hypersexual Disorder Hypoactive Sexual Desire Disorder, Hypersexual Disor-
A. Over a period of at least 6 months, recurrent and intense sexual
der, and Paraphilias, as defined by their respective criteria
fantasies, sexual urges, or sexual behaviors in association with 3 or either infer (Paraphilias: Kafka, 1997b; Kafka & Hennen,
more of the following 5 criteria: 2003) or denote (Hypoactive Sexual Desire Disorder and
A1. Time consumed by sexual fantasies, urges or behaviors repetitively Hypersexual Disorder) disturbances in human sexual desire,
interferes with other important (non-sexual) goals, activities and motivation, and behavior. The elaborated rationale for con-
obligations.
sidering Hypersexual Disorder as primarily as a sexual desire
A2. Repetitively engaging in sexual fantasies, urges or behaviors in
disorder and the derivation of its specific operational criteria
response to dysphoric mood states (e.g., anxiety, depression,
boredom, irritability). will be presented in depth later in this review.
A3. Repetitively engaging in sexual fantasies, urges or behaviors in
response to stressful life events.
A4. Repetitive but unsuccessful efforts to control or significantly Epidemiological Evidence for Hypersexuality
reduce these sexual fantasies, urges or behaviors. Ascertained in Non-Clinical Samples
A5. Repetitively engaging in sexual behaviors while disregarding the
risk for physical or emotional harm to self or others. Any operational definition for hypersexuality should first be
B. There is clinically significant personal distress or impairment in derived from large non-clinical community samples where a
social, occupational or other important areas of functioning
associated with the frequency and intensity of these sexual fantasies, normative range of sexual behaviors can also be ascertained
urges or behaviors. for comparison. Demographic variables, such as age, educa-
C. These sexual fantasies, urges or behaviors are not due to the direct tional attainment, gender, marital/relationship status, reli-
physiological effect of an exogenous substance (e.g., a drug of abuse gious affiliation, and cultural context, must also be taken into
or a medication) account as relevant variables to consider for assessing sexual
Specify if: behavior (Laumann, Gagnon, Michael, & Michaels, 1994;
Masturbation Marmor, 1971; Smith, 2006).
Pornography Kinsey, Pomeroy, and Martin (1948) reported on a large con-
Sexual Behavior with Consenting Adults venience sample of American males (n = 5300). To measure
Cybersex the frequency of sexual behavior, Kinsey et al. assessed a mea-
Telephone Sex sure called total sexual outlet/week (TSO), the cumulative total
Strip Clubs number of orgasms achieved by any single or combination of
Other: sexual behaviors (e.g., masturbation, sexual intercourse, oral
sex). TSO was graphically represented by a continuous distri-
diverse literature that describes these conditions from vary- bution curve skewed to the right (the high frequency end). Only
ing putative pathophysiological perspectives, establishing a 7.6% of American males (adolescence to age 30) had a mean
neutral, broad, and inclusive scientific and medically based TSO of 7 or more for at least 5 consecutive years duration
nosology and diagnostic classification is particularly salient (Kinsey et al., 1948, p. 197). Notably, in that sub-sample of
(Table 1). males, masturbation was the primary sexual outlet in preference
The operational criterion-based definition for Hypersexual to sexual intercourse. Kinsey et al. included a small (n = 81)
Disorder was specifically derived to include elements of two male‘‘underworld’’sample in their American male survey and,
well-established DSM-IV-TR sexual disorders: Hypoactive in that subgroup, 49% self-reported a persistent TSO/week of 7/
Sexual Desire Disorder and the Paraphilias. Hypersexual Dis- week for a minimum duration of 5 consecutive years.
order, however, is defined as a clearly distinct diagnostic cate- Atwood and Gagnon (1987) reported that 5% of high school
gory. and 3% of college age white males (n = 1077) masturbated on
In DSM-IV-TR, Criterion A for Hypoactive Sexual Desire a daily basis, i.e., had a TSO of at least 7 per week. In contrast,
Disorder (HSDD; American Psychiatric Association, 2000) as Pinkerton, Bogart, Cecil, and Abramson (2002) reported that
applied to both men and women, was defined by‘‘persistently the average male undergraduate student reported masturbating
or recurrently deficient (or absent) sexual fantasies and desire an average of 12 times per month (39/week). Laumann et al.
for sexual activity.’’In distinct contrast, Criterion A and B for (1994), in the most recent comprehensive sexuality survey
Hypersexual Disorder are both characterized by an increased of American males and females, reported that only 7.6% of
frequency and intensity of sexual fantasies, urges, and overt American males (n = 1320; ages 18–59) engaged in partnered
behaviors. sex four or more times/week for at least one year. They also
Paraphilias are also characterized by‘‘recurrent, intense sex- reported that only 14.5% masturbated 2–6 times/week for
ually arousing sexual urges or behaviors…that occur over a the current year, 1.9% masturbated daily, and an additional
period of at least 6 months’’; however, the nature of sexual 1.2% masturbated more than once/day during the past year
interest and arousal in paraphilic disorders is not normophilic. (S. Michaels, personal communication, October 18, 1995).
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Inasmuch as these investigators were looking at non-clinical Långström and Zucker (2005) reported similar statistically
samples, they were not able to provide data linking time-con- significant associations in males who acknowledged sexual
suming sexual fantasies and urges (i.e., sexual preoccupation, if arousal from transvestic fetishism with indicators of imper-
present) or social role impairments with orgasm-associated sonal sex/hypersexuality.
sexual behaviors (TSO/week). The Långström and Hanson (2006) report did not define a
Långström and Hanson (2006), in a population-based epi- hypersexual‘‘disorder’’but certainly affords epidemiological
demiological study, defined high rates of enacted sexual behav- support for the prevalence of hypersexual behaviors and their
ior in a large Swedish community sample (n = 2450 men and correlation with a variety of indicators of social and personal
women). They provided an operational definition for ‘‘imper- dysfunction.
sonal sex’’ that included six specific enacted behaviors (fre- Although one dimension for determining a definition for a
quency of masturbation/month, frequency of pornography use/ hypersexual ‘‘disorder’’ as a psychiatric diagnosis could be
year, number of sexual partners in past year and per active year, based on the statistical frequency of enacted sexual behavior,
having extra-partnered sex while in a stable partnered relation- a frequency-based measure alone is merely a‘‘line in the sand’’
ship, and ever participating in group sex) and one attitudinal in the continuous frequency distribution curve of sexual appe-
factor (preferring a casual sexual lifestyle). They utilized a titive behavior. Excessive, repetitive or hypersexual behav-
composite of these measures to identify‘‘hypersexuality’’as an iors without significant personal distress, possible volitional
indicator for the most sexually active 5–10% of their sample. In impairment or significant adverse consequences itself do not
the group of both men and women who were rated as‘‘high’’on designate a clinical or pathological condition. In addition, per-
indicators of hypersexuality, correlations among such sexual sistent and increased total sexual outlet alone, without concom-
behaviors were statistically significant. itant increased sexual fantasies or other expressions of sexual
Males classified in the ‘‘high’’ group in their composite arousal and motivation, might not necessarily be indicative of a
measure of hypersexuality (n = 151 of 1244 men, ages 18–60; sexually motivated disorder.
12.1% of the sample) were more likely to be younger, have
experienced separation from parents, and live in major urban Summary
areas. They were more likely to have started sexual behavior at
an earlier age and, in addition to increased frequency of sexual Although there is no distinct bimodal distribution or taxon
behavior, reported a greater diversity of sexual experiences, that effectively defines‘‘excessive’’sexual behavior or hyper-
including same-sex behavior (but not necessarily being homosexuality into a discrete category, there is significant evidence
sexual), paying for sex, exhibitionism, voyeurism, and mas- from population-based surveys that persistent and increased
ochism/sadism. Their mean TSO/past month was 17.4 ± 11.3 frequency rates of enacted sexual behavior can be ascer-
(median = 17, approximately 49/week), significantly higher tained and may be prodromal to and/or associated with both
than the low and medium hypersexual groups (N. Långström, Paraphilias and Hypersexual Disorder. Adverse consequences
personal communication, November 21, 2008). Despite accrue in a subgroup of these affected individuals and such
acknowledging a higher frequency of sexual behavior, they consequences can be associated with help-seeking behavior
were less likely to feel satisfied with their sexual life, had more and clinical assessment.
relationship-associated problems, more STDs, and were more
likely to have consulted professional help for sexuality-related
issues. Contemporary Pathophysiological Models
In the female sample (n = 1171, age range, 18–60), 6.8% for Hypersexual Disorder
(n = 80) of the sample met criteria for‘‘high hypersexuality.’’
It is of interest that women defined as hypersexual were quite A lack of consensus regarding the pathophysiology of these
similar to males in the aforementioned variables but, in addi- sexual behavior disorders as well as a modest volume of
tion, women were more likely to report a history of sexual empirical data in peer-reviewed journals has continued to
abuse and had sought psychiatric care in the last year. Women hamper the specific characterization of maladaptive nonpara-
in the high hypersexual group had a significantly higher mean philic sexual behaviors as a distinct diagnostic class of dis-
TSO/past month (13.0 ± 9.1/month or 39/week; median = orders (Bancroft & Vukadinovic, 2004; Rinehart & McCabe,
11) in comparison with the low and medium hypersexual 1997) and to delineate the intra-class relationships between
groups (N. Långström, personal communication, November the putative disordered sexual behaviors that are affected.
21, 2008). While some theoreticians have doubted the validity of estab-
Both males and females in the ‘‘high hypersexuality’’ lishing any diagnostic category for normophilic sexual behav-
group engaged in other risk-taking behaviors, such as smok- ior disorders (Giles, 2006; Rinehart & McCabe, 1997), a
ing cigarettes, heavy drinking, the use of illegal drugs, and, in research and clinical literature of differing theoretical per-
males, gambling. In a separate report with the same sample, spectives has posited whether such disorders are primarily
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Arch Sex Behav (2010) 39:377–400 381
sexually motivated (analogous to paraphilias) (Kafka, 2007; Psychiatric Association, 2000), and sexual aggression (Knight
Krueger & Kaplan, 2001; Stein, Black, & Pienaar, 2000), behav- & Sims-Knight, 2003, 2004).
ioral addictions (Carnes, 1983; Goodman, 1997), obsessive– Kafka (1993, 1994, 1995a, b, 1997b, 2000, 2001, 2003a,
compulsive spectrum disorders (Black, 1998; Coleman, 1987, 2007; Kafka & Hennen, 1999, 2003; Kafka & Prentky, 1992)
1990), impulsivity-spectrum disorders (Hollander & Rosen, has reported on clinical samples of males with paraphilias
2000; McElroy et al., 1996; Mick & Hollander, 2006) or (PAs) and paraphilia-related disorders (PRDs). Paraphilia-
‘‘out of control’’ excessive sexual behaviors (Bancroft & related disorders were defined as a specific class of normo-
Vukadinovic, 2004). These theoretical models and their philic sexual behavior disorders distinct from, but also co-
empirical foundations will be next reviewed. associated with, PAs. PRDs were characterized as markedly
increased expressions of culturally normative sexual desire
(fantasies, urges, and behaviors) persisting for a minimum
Sexual Desire Dysregulation duration of 6 months and associated with clinically significant
personal distress, impairment in reciprocal romantic rela-
In the human sexuality literature, sexual desire refers to the pre- tionships or other adverse psychosocial consequences.
sence of sexual fantasies, urges or activities, and the subjective An operational definition for ‘‘hypersexual desire’’ based
conscious motivational determination to engage in sexual on a lifetime assessment of the frequency of sexual behavior
behavior in response to relevant internal or external cues (Amer- as well as current measurements of time spent in PA and PRD-
ican Psychiatric Association, 2000; Bancroft, 2009; Kaplan, associated sexual fantasies, urges, and behavior was derived
1995; Leiblum & Rosen, 1988; Levin, 1994; Levine, 2002; from 220 consecutively evaluated males with PAs and PRDs
Singer & Toates, 1987). This definition is analogous to the (Kafka, 1997b, 2003a; Kafka & Hennen, 2003). From these
appetitive or incentive-motivational phase of sexual behavior clinically derived data, hypersexual desire in adult males was
described in other male mammalian species. Sexual desire, in defined as a persistent TSO of 7 or more orgasms/week for at
association with sexual arousal, may be expressed with a part- least 6 consecutive months after the age of 15 years.
ner or through solitary masturbation (Spector, Carey, & Stein- Kafka’s proposed operational definition for hypersexual
berg, 1996). desire was formulated to reflect Kinsey et al. (1948), Atwood
Evolutionary theory proponents have argued that men and and Gagnon (1987), Janus and Janus (1993), and Laumann
women differ in mating strategies and that such differences are et al.’s (1994) normative data on the range of sexual behavior
evident cross-culturally (Buss & Schmitt, 1993). Many studies in American males as well as their data characterizing the
have reported that human males, in comparison to females, are most sexually active 5–10% of their samples.
distinguished by increased sexual fantasy (Leitenberg & Hen- A longitudinal history of hypersexual desire, as opera-
ning, 1995), increased frequency of masturbation (Laumann tionally defined above, was identified in 72–80% of males
et al., 1994; Leitenberg, Detzer, & Srebnik, 1993), increased seeking treatment for paraphilias and paraphilia-related dis-
propensity for externally generated visual sexual arousal (Jones orders (Kafka, 1997b, 2003a; Kafka & Hennen, 2003). If the
& Barlow, 1990), more permissive attitudes toward casual sex TSO/week threshold for hypersexual desire were reduced to
(Oliver & Hyde, 1993) and more intrinsic sexual motivation 59/week for a minimum duration of 6 months, this would
and ease of arousal (Bancroft, Graham, Janssen, & Sanders, have included 90% of the sample.
2009; Okami & Shackelford, 2001). Consistent with these data, The most commonly enacted lifetime sexual behavior in
it has been hypothesized that women’s sexual motivation, these clinically derived samples was masturbation, not part-
sexual arousal, and sexual behavior are shaped by evolution- nered sex, as was similarly reported by Kinsey et al. (1948, p.
ary factors, such as women’s greater biological, emotional, 197) and Långström and Hanson (2006) in men who were the
and temporal investment in reproduction and child rearing most sexually active in their samples. The mean age of onset
(Buss & Schmitt, 1993; Trivers, 1972). Women’s sexual of persistent hypersexual behavior was 18.7 ± 7.2 years, the
desire may be more context responsive in comparison to the age range of onset of hypersexual behavior was age 7–46, and
spontaneous sexual desire reported by males (Basson, 2001; the mean duration of this highest consistently maintained fre-
Brotto, 2009). In comparison to males, female sexuality is quency of sexual appetitive behavior was 12.3 ± 10.1 years.
better adapted to foster affiliative relationships and longer In contrast, the mean age of this group when they sought
term partner commitment (Anderson, Cyranowski, & Aares- treatment was 37 ± 9 years. Periods of persistent hypersexual
tad, 2000). From these data, it would certainly follow that behavior were continuous or episodic.
males are more vulnerable to hypersexual behaviors (Dodge, There were no statistically significant differences between
Reece, Cole, & Sandfort, 2004; Långström & Hanson, 2006), men with paraphilias and paraphilia-related disorders in indi-
Hypersexual Disorder (Black, Kehrberg, Flumerfelt, & ces of lifetime hypersexual behavior frequency, duration of
Schlosser, 1997; Briken, Habermann, Berner, & Hill, 2007; hypersexual behavior, and current indices of sexual activ-
Raymond, Coleman, & Miner, 2003), paraphilias (American ity, sexual fantasies, urges, and behaviors (1–2 h time spent/
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382 Arch Sex Behav (2010) 39:377–400
day/week associated exclusively with PA and/or PRD-associ- The ‘‘dual control’’ model was utilized to study non-
ated sexual fantasies, urges, and behaviors). Males with the high- paraphilic ‘‘out of control’’ sexual behaviors (Bancroft &
est cumulative lifetime number of paraphilias and paraphilia- Vukadinovic, 2004). Self-identified predominantly male‘‘sex-
related disorders (5 or more), however, self-reported a higher ual addicts’’ (n = 31) scored higher on the MSQ and SES but
current TSO/week (mean 10 orgasms/week) and increased not SIS1 or SIS2 in comparison to an age matched control
time consumed by PA and/or PRD-associated sexual fanta- group. Consistent with others investigators describing these
sies, urges, and behaviors (mean 2–4 h/day). Other investi- conditions (Carnes, 1989; Coleman, 1990; Kafka, 1991),‘‘neg-
gators have also reported a positive correlation between the ative’’mood states, particularly anxious and depressive mood,
frequency of sexual fantasy, masturbation, number of life- can be associated with both sexual promiscuity and increased
time sexual partners, and self-rated sexual drive (Giambra & masturbation in gay as well as heterosexual men (Bancroft,
Martin, 1977; Laumann et al., 1994; Wilson & Lang, 1981). Janssen, Strong, & Vukadinovic, 2003c; Bancroft et al., 2003b).
Researchers affiliated with the Kinsey Institute have devel- Winters et al. (2007) have reported on a large convenience
oped a ‘‘dual control model’’ of sexual arousal that hypothe- sample derived from an Internet-based survey of sexual
sizes centrally mediated (i.e., neurobiological) sexual excit- behavior. They initially reported a sample of 7841 males
atory and inhibitory processes (Bancroft, 1999; Bancroft & and females (Winters et al., 2007) that was more recently
Janssen, 2000; Janssen, Vorst, Finn, & Bancroft, 2002a). In expanded to include 14,396 subjects (6458 males and 7938
addition, their research has tested a hypothesis that subgroups females; Winters et al., 2009). In the latter expanded sample,
of gay and heterosexual males respond to anxious or depres- the participants were predominantly white, North American
sive affect with increased sexual behavior. college graduates whose mean age was 29 years. In their larger
To assess these putative mechanisms, they have devel- sample, 107 (1.6%) men and 69 (0.8%) women acknowledged
oped validated scales, the Mood and Sexuality Questionnaire having sought treatment for ‘‘sexual compulsivity.’’ Their
(MSQ), to assess the relationship between anxious and depres- assessment methodology included administering a series of
sive affect and sexual behavior, and the Sexual Inhibition well-validated rating scales, including the Sexual Compul-
Scales (SIS1 and SIS2) and Sexual Excitation Scale (SES), to sivity Scale (SCS) (Kalichman & Rompa, 1995, 2001) as a
assess sexual arousal in males and females. These scales were dimensional measure of dysregulated sexual behavior, and
administered to examine how excitation and inhibition dif- the Sexual Inhibition and Sexual Excitation Scales (SIS/SES)
fer in different social contexts as well as in different clinical (Carpenter et al., 2008; Janssen et al., 2002a, b), the Sexual
groups (Carpenter, Janssen, Graham, Vorst, & Wicherts, 2008; Desire Inventory-2 (Spector et al., 1996), and the Deroga-
Janssen, Goodrich, Petrocelli, & Bancroft, 2009; Janssen, Vorst, tis Sexual Functioning Inventory (Derogatis & Melisaratos,
Finn, & Bancroft, 2002b; Janssen et al., 2002a). 1979) to assess sexual desire and associated behaviors. They
In this model, persons with combinations of either low inhi- reported that the relationship between dysregulated sexual
bition (SIS2; i.e., not inhibited by the threat of performance con- behavior and sexual desire was best accounted for by a single
sequences) and/or high on measures of sexual excitation and latent variable. That is, sexual compulsivity or‘‘dysregulated’’
arousal (SES), accompanied by anxious or depressive affect, sexual behavior was primarily a marker of increased sexual
could be ‘‘sexual risk-takers’’ prone to promiscuous behavior desire and the distress associated with managing the frequency
and/or increased masturbation (Bancroft & Vukadinovic, 2004; and intensity associated with increased partner-associated as
Bancroft et al., 2003a, 2004; Janssen et al., 2009). In contrast, well as solitary sexual behavior (i.e., masturbation) (Winters
low SES scores were associated with ‘‘asexuals,’’persons with et al., 2009).
disinterest or low motivation in sex (Prause & Graham, 2007). A complementary neurobiological formulation for a sex-
The extensive development and continued empirical testing of ual desire dysregulation model has been presented as a‘‘mono-
this model is best summarized by Bancroft et al. (2009). This amine hypothesis’’ for paraphilic disorders (Kafka, 1997a,
model to assess sexual arousal, sexual appetitive behavior, and 2003b; Kafka & Coleman, 1991). This formulation can also be
sexual risk-taking is the most methodologically rigorous, empir- applied to Hypersexual Disorder as well inasmuch as both PAs
ically grounded, and informative to date. and Hypersexual Disorder are associated with intense and fre-
While the dual control model was formulated to examine quent sexual fantasies, urges, and activities and adverse con-
sexual ‘‘arousal’’ and sexual response, sexual arousal is a sequences. This model was derived from laboratory-based
component of sexual desire (Bancroft, 2009) and increased evidence demonstrating that brain monoaminergic receptors
sexual excitation, as measured by the SES, is associated (serotonin, dopamine, and norepinephrine) interacting with
with both increased sexual arousal and appetitive behavior sex hormone receptors, especially testosterone and other neuro-
in men and women (Bancroft et al., 2009; Prause, Janssen, modulators, provide a biological substrate for sexual appeti-
& Hetrick, 2008; Sanders, Graham, & Milhausen, 2008; tive and copulatory response behaviors in mammals (Everitt,
Winters, Christoff, & Gorzalka, 2009; Winters, Christoff, 1995; Everitt & Bancroft, 1991; Gorzalka, Mendelson, &
Lipovsky, & Gorzalka, 2007). Watson, 1990; Mas, 1995; Mas, Fumero, Fernandez-Vera, &
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Arch Sex Behav (2010) 39:377–400 383
Gonzalez-Mora, 1995; Meston & Frolich, 2000; Pfaus, 1996). domains affected by all of the aforementioned addictive pro-
In these aforementioned reports assessing mammalian sexual cesses: motivation-reward, affect regulation, and behavioral
behavior, enhanced dopaminergic neurotransmission is asso- inhibition.
ciated with sexual excitation while enhanced serotonergic DSM-based nosology has not, however, previously explic-
neurotransmission is associated with sexual inhibition. Labo- itly endorsed ‘‘addiction’’ as a diagnostic category; instead, it
ratory-induced perturbations of these monoamine neurotrans- differentiates substance abuse (a pattern of pathological use
mitters, especially serotonin (Ferguson et al., 1970; Sheard, and associated impairment) from substance dependence (abuse
1969; Tagliamonte, Tagliamonte, Gessa, & Brodie, 1969) and pattern, adverse consequences, drug tolerance and withdrawal)
dopamine (Baum & Starr, 1980; Everitt, 1990), can profoundly (American Psychiatric Association, 2000). From this perspec-
affect sexually motivated behaviors and provoke sexual dis- tive, and paraphrasing the DSM-IV-TR definition of substance
inhibition or hypersexual behavior in non-human primates. dependence, Goodman (2001) proposed that sexual addiction
In studies of human males, Axis I comorbid conditions could be analogously operationally defined by considering
(see discussion later in this review) associated with both excessive sexual behavior as a dependency syndrome where
PAs and Hypersexual Disorder, including unipolar (Risch & such behavior substitutes for a psychoactive substance in 3 of
Nemeroff, 1992) and bipolar (Lasky-Su, Faraone, Glatt, & the 7 operational criteria required for the substance dependence
Tsuang, 2005) mood disorders, anxiety disorders (Kahn, diagnosis (American Psychiatric Association, 2000).
Westenberg, & Verhoevan, 1987), and impulsivity disorders In the peer-reviewed literature, there is some empirical
(Kavoussi, Armstead, & Coccaro, 1997; Soubrie, 1986) as support for sex as a behavioral addiction or dependency
well as attention deficit hyperactivity disorders (Levy, 1991) syndrome. Wines (1997) distributed 183 questionnaires to a
are associated with perturbations of central monoaminergic sample of self-identified sex addicts. In the 53 respondents
neurotransmission as well, thereby providing a possible (males; n = 47: females; n = 6), he found substantial support
neurobiological bridge between Axis I psychiatric disorders, for sexual dependence. In respondents, 98% reported three
testosterone, monoaminergic neurotransmitters, and disin- or more withdrawal symptoms, 94% had made unsuccessful
hibited sexual behaviors. attempts to control or reduce addictive sexual behaviors,
94% spent significant time preparing for or recovering from
Sexual Addiction and Sexual Dependence addictive sexual behaviors, and 92% reported that they
engaged in longer or greater amounts of sexual behavior than
Orford (1978, 1985) suggested that excessive appetitive and they intended. This study, however, was limited by ascer-
consummatory behaviors, including promiscuous hypersex- tainment bias—a self-identified group of sexual addicts attend-
uality, could become an addiction-like behavioral syndrome ing a 12-step recovery program.
despite the absence of an exogenous substance of abuse. Since Carnes (1989, 1991b) has published the Sexual Addiction
the publication of Carnes’ (1983) descriptive and conceptual Screening Test (SAST), a 25-item dichotomously answered
book Out of the Shadows: Understanding Sexual Addiction, self-administered questionnaire that is also available (ver-
the clinical concept of sexual addiction has become widely sion 3.1) modified for homosexual men and women (www.
popularized (Carnes, 1989, 1990, 1991a; Carnes & Adams, sexhelp.com). The SAST has demonstrated a single factor
2002). This clinical term has been especially embraced in the with high internal consistency in a sample of 191 sexually
popular press and has resonated to persons suffering from addicted in comparison with 67 non-addicted males. A cutoff
either repetitive paraphilic and/or nonparaphilic sexual behav- score of 13 (out of 25) is likely indicating the presence of a
iors associated with progressive risk-taking sexual behaviors, sexual addiction in heterosexual males (Carnes, 1989).
‘‘loss of control,’’and significant adverse psychosocial conse- Nelson and Oehlert (2008) administered the SAST to two
quences. groups of male veterans in a psychoactive substance abuse
Central to Carnes’ (1983, 1989) formulation and the addic- treatment program (n = 313; n = 316). In their report, the
tion model is the repetitive misuse of sexual behavior to man- SAST also measured a single construct with excellent reli-
age dysphoric affects (i.e., self-medication), an escalation or ability and acceptable convergent validity. A more compre-
progression of sexual behaviors (tolerance and risk-taking), a hensive diagnostic instrument, the Sexual Dependency Inven-
‘‘loss of control,’’ adverse psychosocial consequences, and a tory-Revised, has also been described (Delmonico, Bubenzer,
withdrawal state. Carnes formulation of sexual addiction has & West, 1998).
been elaborated by Goodman (1997), who provided a multi- The neurobiology associated with psychoactive substance
factorial model of the addictive process and proposed that dependency has been elucidated in animal models. The neg-
psychoactive substances of abuse, bulimia, pathological gam- ative emotional state that drives ‘‘compulsive’’ drug use is
bling, and sexual addiction share a common substrate of hypothesized to derive from dysregulation of key neurotrans-
biological, psychological, and developmental factors. More mitters involved in distinct reward and stress-associated neu-
recently, Goodman (2008) has posited three behavioral ral circuits within the basal forebrain structures, particularly
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the ventral striatum (including the nucleus accumbens) and and the Sexual Sensation Seeking Scale (SSSS), an 11 item
extended amygdala. Specific neurochemical elements in these scale to evaluate risk taking associated with repetitive promis-
structures associated with psychoactive substance dependence cuous behavior (Kalichman & Rompa, 1995, 2001; Kalich-
can include decreases in dopamine, serotonin, and opioid pep- man, Kelly et al., 1997). The SCS scale was derived from self-
tides in the ventral striatum, but also recruitment of brain stress descriptions of persons primarily self-identified as having
neurohormones, such as corticotrophin-releasing factor in the sexual addiction. The 10 items have alpha coefficients
extended amygdala (Koob, 2008). ranging from 0.85 to 0.91. The SCS has been extensively
In humans, the orbital prefrontal cortex and ventral ante- employed to identify‘‘sexual risk-takers.’’Sexual risk takers
rior cingulate cortex are functionally associated with moti- included men who have frequent sex with different men in
vation, reward appraisal, and mediation/inhibition of impul- community settings, participate in ‘‘risky sexual behaviors,’’
sive aggression (Best, Williams, & Coccaro, 2002; Horn, including increased frequencies of unprotected sexual inter-
Dolan, Elliott, Deakin, & Woodruff, 2003; New et al., 2002). course, unprotected anal intercourse, and greater numbers
The dysregulation in these brain circuits in their relationship of sexual partners or have acquired sexually transmitted
with limbic structures, particularly the amygdala, have been diseases (Dodge et al., 2008; Kalichman & Cain, 2004),
detected by fMRI and neuroimaging procedures as well as including HIV infection (Kalichman, Cherry, Cain, Pope, &
sophisticated neuropsychological testing in impulsivity dis- Kalichman, 2005). In a sample of 296 homosexual males as
orders, including substance abuse disorders and behavioral well as 158 low-income inner-city men and women, the SCS
addictions (Bechara, 2005; Cavedini, Riboldi, Keller, D’An- captured dimensions of sexual behavior characterized as
nucci, & Bellodi, 2002; London, Ernst, Grant, Bonson, & hypersexuality (maladaptive behaviors, intensified sexual
Weinstein, 2000; Volkow & Fowler, 2000). The application of appetite, volitional impairment, adverse consequences) and
neurobiological studies to putative human sexual addiction sexual preoccupation (Kalichman & Rompa, 1995). The SCS
would be helpful to clarify whether a similar neurobiology and has also been reported to have reliability and validity to iden-
neural pathways are applicable. tify sexual compulsivity in two college samples of males and
females (Dodge et al., 2004; n = 876; McBride, Reece, &
Sexual Compulsivity Sanders, 2008; n = 390). Higher scores on the SCS correlated
with increased number of sexual partners, risky sexual behav-
Quadland (1983, 1985) suggested the term ‘‘sexual compul- iors, and increased solo sexual behaviors (masturbation).
sivity’’ to describe volitional impairment and risk-taking The psychometric properties of the Compulsive Sex-
behaviors associated with hypersexual behavior, particularly ual Behavior Inventory (CSBI) have also been examined
promiscuous homosexual behavior. ‘‘Sexual compulsivity’’ (Coleman, Miner, Ohlerking, & Raymond, 2001; Miner,
as a descriptive appellation has continued to be consistently Coleman, Center, Ross, & Rosser, 2007). The CSBI taps into
applied to men who are sexual sensation seekers/risk-takers two factors associated with sexual compulsivity: inability
(Kalichman & Rompa, 1995; Zuckerman, 1983), have mul- to control sexual fantasies, urges, and behaviors and inter-
tiple sexual partners (i.e., are promiscuous), and are at higher personal violence/harm associated with sexual behavior. In
risk for HIV infection and other sexually transmitted diseases Miner et al. (2007), a sample of 1026 Latino males were
(STDs) (Kalichman & Cain, 2004; Kalichman, Greenberg, & recruited and assessed utilizing Internet-based technology.
Abel, 1997; Kalichman, Kelly, & Rompa, 1997; Parsons, Participants with scale scores above the median had more
Kelly, & Bimbi, 2008). sexual partners and engaged in more unprotected sexual
Since 1986, ‘‘sexual compulsivity’’ has been a descriptive intercourse than those with CSBI scores below the median,
term applied to a substantially broader range of both paraphil-
ic and nonparaphilic sexual behavior disorders by Coleman
Impulsivity Disorders: Sexual Impulsivity
(1986, 1987, 1992) and the term has been adopted by others
and Impulsive–Compulsive Sexual Behavior
clinical investigators (Anthony & Hollander, 1993; Black,
1998; Black et al., 1997; Hollander, 1993; Travin, 1995). In
At the same time that the competing models of sexual addic-
Coleman’s (1987, 1990) original formulation, compulsive sex-
tion and sexual compulsivity were first being described,
ual behavior disorders were repetitive behaviors mediated by
Barth and Kinder (1987) suggested that the best fit model for
the behavioral attempts to reduce anxiety and other dysphoric
excessive sexual behaviors was as an atypical impulse con-
affects (e.g., shame, depression) and was symptomatic of an
trol disorder. In the Diagnostic and Statistical Manuals
‘‘underlying obsessive compulsive disorder.’’‘‘Sexual obses-
(American Psychiatric Association, 1980, 1987, 1994, 2000),
sion’’ described the increased, time consuming sexual fantasy
impulse control disorders have been characterized by:
associated with compulsive sexual behavior.
Kalichman developed the Sexual Compulsivity Scale the failure to resist an impulse, drive or temptation to
(SCS), a validated 10 item scale to assess sexual compulsivity perform an act that is harmful to the person or others….
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Arch Sex Behav (2010) 39:377–400 385
A person may feel an increased sense of tension or of substance dependence syndromes (Koob, 2008), perhaps
arousal before committing the act and then experiences providing a parallel for Hypersexual Disorder when it is asso-
pleasure, gratification, or relief at the time the act is ciated with an escalating course, volitional impairment, and
committed. Following the act, there may or may not be progression of adverse consequences.
regret, self-reproach or guilt. (American Psychiatric Some of the coalescence of differing terminologies is dem-
Association, 2000, p. 663) onstrated by the following examples. Raviv (1993) compared
male and female sex addicts (n = 32) to pathological gamblers
In the Impulsivity Not Otherwise Specified section of the
(n = 32) and non-addicts (n = 38) by administering the Symp-
DSM manuals, it is noted that several other DSM-defined Axis
tom Checklist-90 (SCL-90) (Derogatis, 1977) and Zucker-
I and Axis II disorders, including Paraphilias,‘‘may have fea-
man’s (1979) Sexual Sensation Seeking Scale. Both the sexual
tures that involve problems of impulse control.’’
addicts and gamblers self-reported significantly more neurot-
Sexual‘‘risk taking’’(Bancroft et al., 2003a, 2004; Kalich-
icism-depressive and anxious affect, obsessive–compulsive
man & Rompa, 1995, 2001) and sexual ‘‘sensation seeking’’
characteristics, and interpersonal sensitivity than the control
(Kalichman & Rompa, 1995; Zuckerman, 1979, 1983) are devel-
group.
oped constructs that overlap considerably with each other and
Grant, Levine, Kim, and Potenza (2005) studied the prev-
with sexual ‘‘impulsivity’’ (Hoyle, Fefjar, & Miller, 2000).
alence of impulsivity disorders, including sexual compul-
These dimensional measures have been applied particularly to
sivity, in an inpatient psychiatric sample of 204 consecu-
sexual behaviors associated with the transmission of sexually
tively admitted patients (n = 112 females; n = 92 males) by
transmitted diseases, such as sexual relations with multiple
administering the Minnesota Impulsivity Disorders Inter-
partners, unprotected sex, and unplanned pregnancies. Sexual
view. In their sample, 31% were diagnosed with at least
risk-taking and impulsivity are also associated with multiple
one lifetime impulsivity disorder. Ten subjects (4.9%, gen-
forms of psychoactive substance abuse (Hayaki, Anderson, &
der, unspecified) met lifetime criteria for sexually compul-
Stein, 2006; Justus, Finn, & Steinmetz, 2000; Lejuez, Simmons,
sive behavior. Nine of these ten also reported a current sex-
Aklin, Daughters, & Dvir, 2004). Impulsivity as a personality
ually compulsive behavior. Raymond et al. (2003) reported
trait is associated with individual differences in the propensity
on 23 males and 2 females with compulsive sexual behaviors
to engage in high-risk sexual behaviors (Seal & Agostinelli,
and found that their sample reported more traits of impul-
1994; Teese & Bradley, 2008). Pathological gambling, an
sivity than compulsivity using a semi-structured interview
Impulsivity NOS Disorder, can also be associated with sexual
that they developed.
risk-taking behaviors in men (Martins, Tavares, da Silva
Lobo, Galetti, & Gentil, 2004).
Impulsivity and compulsivity have been conceptualized as Summary
dimensional measures and both impulsivity-spectrum and
compulsivity-spectrum disorders have been proposed to over- The data reviewed from these varying theoretical perspectives
lap and include sexual impulsions, compulsions, addictions, is compatible with the formulation that Hypersexual Disorder
and paraphilias (Hollander & Rosen, 2000; McElroy, Phillips, is a sexual desire disorders characterized by an increased fre-
& Keck, 1994). To account for this overlap and the amalgam- quency and intensity of sexually motivated fantasies, arousal,
ation of impulsive and compulsive features, a still broader urges, and enacted behavior in association with an impulsivity
group of impulsive–compulsive disorders, the non-substance component—a maladaptive behavioral response with adverse
abuse behavioral addictions, have been proposed to include consequences. Hypersexual Disorder can be associated with
sexual addiction, some eating disorders (obesity and binge- vulnerability to dysphoric affects and the use of sexual behav-
eating disorder), compulsive shopping, and internet gam- ior in response to dysphoric affects and/or life stressors asso-
ing (N. Petry, personal communication, October 31, 2008; E. ciated with such affects. It is well documented that the sexual
Hollander, personal communication, December 7, 2008). behaviors associated with Hypersexual Disorder, particularly
Indeed, the overlap among concepts such as addiction, com- sexual behavior with consenting adults, are associated with
pulsivity, and impulsivity as applied to excessive sexual behav- risk-taking or sensation seeking as well. It is possible as well
iors leads to an increasingly confusing review of the recent that a risk taking dimension is associated with the progression
research and clinical literature as these conceptual framework of other Hypersexual Disorder subtypes, such as pornography
were initially distinctive and competitive (Coleman, 1986) and or cybersex (see section on Hypersexual Disorder specifiers).
supposedly independent constructs associated with the puta- Hypersexual Disorder is associated with increased time
tive pathophysiology of repetitive maladaptive sexual behav- engaging in sexual fantasies and behaviors (sexual preoccu-
ior disorders. In addition, the psychoactive substance depen- pation/sexual ‘‘obsession’’) and a significant degree of voli-
dence literature describes‘‘impulsivity’’as associated with the tional impairment or ‘‘loss of control’’ characterized as dis-
early stage and‘‘compulsivity’’ associated with the late stages inhibition, impulsivity, compulsivity, or behavioral addiction.
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386 Arch Sex Behav (2010) 39:377–400
Although distinct putative pathophysiological models have Compulsive masturbation had a 70% sample prevalence in
been hypothesized to characterize the increased frequency a clinical sample of 206 consecutively evaluated males with
and intensity of urges of nonparaphilic sexual behaviors and paraphilias and paraphilia-related disorders (Kafka & Hen-
their impulsivity-associated component, many of these models nen, 1999). It was significantly associated with all other para-
overlap and converge. As aptly stated in the DSM manuals, philia-related disorders except protracted promiscuity, and
Paraphilias are Sexual Disorders with ‘‘features that include was significantly associated with all paraphilic disorders,
problems associated with impulse control’’ (American Psy- especially telephone scatologia. Indeed, in males with PAs or
chiatric Association, 2000, p. 663). Based on the data reviewed, PRDs, masturbation was the most common sexual outlet over
this same description applies to Hypersexual Disorder. the course of a lifetime, regardless of marital status (Kafka,
1997b).
Pornography dependence was reported by 50% of the sam-
What Behaviors (DSM Specifiers) Are Affected ple (Kafka & Hennen, 1999) and was significantly associated
in Hypersexual Disorder? with compulsive masturbation and telephone sex depen-
dence. Pornography included, but was not specifically lim-
The sexual addiction literature, while rich in description of indi- ited to, visual as well as explicitly sexually arousing text
vidual sex addicts and possible treatments, has lacked a coher- materials, including magazines, internet images, and videos.
ent codification for the specific hypersexual behaviors that are In the published literature describing paraphilia-related dis-
reliably or consistently reported in clinical or research reports. orders, pornography dependence was applied to men whose
For example, initial classifications included 11 broadly defined problems associated with pornography dependence included
behaviors, such as fantasy sex, seductive role sex, intrusive sex, both child and adolescent as well as adult pornographies. The
voyeuristic sex, and paying for sex (Carnes, 1991a; Delmonico recent advent of internet-related pornography has greatly
et al., 1998) that would be difficult to operationally define across increased the accessibility and affordability of both legal and
studies. Wines (1997) studied 53 participants in a survey on sex- illegal pornography while maintaining anonymity for its use
ual addiction and reported that the most common lifetime rep- (Cooper, 1998). In addition, the use of internet pornogra-
resentations of such behaviors were fantasy sex (77%), compul- phy in the workplace setting has provoked a variety of indus-
sive masturbation (75%), voyeuristic sex (71%), anonymous sex try-based responses to this problematic behavior (Cooper,
(47.2%), and multiple sexual partners (45.3%). Inasmuch as Golden, & Kent-Ferraro, 2002). While the collection and
sexual addiction is conceptualized as a pathophysiological viewing of pornography is inherently a normophilic sexual
mechanism that can include both paraphilic and nonparaphil- activity, the content of pornography associated with Hyper-
ic behaviors, in a more recent publication, sexually addictive sexual Disorder may reflect either/both normophilic and
behaviors have included compulsive masturbation, affairs, paraphilic sexual arousal.
use of prostitutes, pornography, cybersex, prostitution, voyeur- Telephone sex dependence had a 25% sample prevalence
ism, exhibitionism, sexual harassment, and sexual offending (Kafka & Hennen, 1999) and was associated with significant
(Carnes & Wilson, 2002). financial debt and the use of phone blocks. Telephone sex
Compulsive sexual disorders have included compulsive dependence was significantly associated with compulsive
cruising and multiple partners, compulsive fixation on an unat- masturbation, pornography dependence, and protracted pro-
tainable partner, compulsive autoeroticism, compulsive use of miscuity. Interestingly, it was also significantly associated
erotica, compulsive use of the internet, compulsive multiple with telephone scatologia (obscene telephone calls).
love relationships, and compulsive sexuality in a relationship Cybersex would include the use of the internet to meet
(Coleman, Raymond, & McBean, 2003). In a sample of 25 potential sexual partners or engage in ‘‘virtual sex’’ while in
subjects (including 2 females), Raymond et al. (2003) reported chat rooms or with web-cams. Cybersex may include a ‘‘vir-
that compulsive cruising and multiple relationships (n = 19) tual’’partner in real-time but is still a masturbation-associated
and compulsive masturbation, i.e., autoeroticism (n = 12), were Hypersexual Disorder (Cooper, Delmonico, Griffin-Shelly, &
the most common compulsive sexual behaviors. Less fre- Mathy, 2004; Daneback, Cooper, & Månsson, 2005).
quently, phone sex, compulsive use of sexual sites on the Cybersex has been most extensively studied by Cooper
internet, and compulsive sexuality within a relationship were (Cooper, 1998; see also Cooper, Delmonico, & Burg, 2000;
also reported in association with compulsive masturbation Cooper, Scherer, Boies, & Gordon, 1999; Cooper et al.,
and multiple relationships. 2004). In those studies, however, internet pornography users
Although other investigators utilize different terminology (predominately males) and chat-room participants (predom-
(Carnes & Wilson, 2002; Coleman et al., 2003), these fol- inantly women) were combined in the cybersex samples.
lowing specific behaviors are generally consistent across the Newsgroup (listserv) participants tend to be males seeking
aforementioned models for Hypersexual Disorder. specialized pornography forums. It is likely then that each
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Arch Sex Behav (2010) 39:377–400 387
of these internet-related domains could represent different sexual behaviors did not suffer from a precedent or con-
populations of male and female users (Cooper et al., 2000). current sexual dysfunction (Kafka, 2000; Kafka & Hennen,
Both males and females who self-identified as sexually com- 1999). Severe sexual desire incompatibility was significantly
pulsive regarding computer-associated sex and relationships associated with compulsive masturbation and sexual sadism.
were engaging in such behavior at least 1–2 h/day (7–14 or It is important to emphasize that this disorder is not merely
more h/week) (Cooper et al., 1999; Daneback et al., 2005; Del- describing a couple characterized, for example, by a married
monico & Miller, 2003), the same amount of time consumed man who desires partnered sex 2 or 3 times/week with a reluc-
by problematic sexual behaviors for males seeking outpatient tant partner. Most men and women who reported this PRD
treatment for other PA and PRDs (Kafka, 1997b, 2003a; Kafka have periods of wanting or demanding near daily sex (or
& Hennen, 2003). Frequent users of cybersex whose goal is to more), including, for example, repetitively waking up their
meet partners are more likely to acquire sexually transmitted partner for sexual intercourse. Their affected partner feels
diseases (McFarlane, Sheana, & Rietmeijer, 2000) and should sexually exploited, demeaned or angry. In some instances,
be assessed for protracted sexual promiscuity (Sexual Behav- severe sexual desire incompatibility may be associated with
ior with Consenting Adults) as well. Some predatory cybersex sexual coercion and partner rape. In the consideration of
users may use this medium to communicate with and try to severe sexual desire incompatibility as a possible specifier for
meet children and adolescents as well. Hypersexual Disorder, the issue was raised that such a desire
In a large sample derived from the internet site www.Sex incompatibility was or would be defined in the context of a
help.com (males = 5005; females = 1083), sexually compul- relational partnership rather than as a disorder within a spe-
sive subjects were initially distinguished from non-com- cific individual. For this reason, it was decided at this time not
pulsives on the basis of their scores on the Sexual Addiction to designate severe sexual desire incompatibility as a speci-
Screening Test (Carnes, 1989, 1991a). The Internet Sex Screen- fier for Hypersexual Disorder.
ing Test, which has seven empirically derived scales, showed The frequenting of‘‘strip clubs’’with clinically significant
some promise to specifically discriminate excessive and prob- adverse consequences (typically financial) should be con-
lematic use of the Internet as a sexual outlet in both males sidered as a distinct Hypersexual Disorder specifier. For
(n = 2013) and females (n = 553) in comparison to the non- many men who just go to watch the show (and typically
compulsive group (n = 2566). Subjects rated as sexually com- imbibe alcoholic beverages), this is a modified form of‘‘live’’
pulsive regarding their Internet use reported more time spent visual pornography. Masturbation may take place at the club
viewing or reading sexual content, more money spent, non- or shortly thereafter. For others, strip club attendance is asso-
home use of computers to access sexual content and accessing ciated with repetitive adult partnered-associated sex, typi-
illegal sexual materials. cally for a significant fee. Thus, although repetitive atten-
Protracted promiscuity, a Hypersexual Disorder designated dance to strip clubs could be codified as either Hypersex-
as Sexual Behavior with Consenting Adults, can be subdivided ual Disorder: Pornography or Hypersexual Disorder: Sexual
into heterosexual, bisexual, and homosexual subtypes. This Behavior with Consenting Adults, I would recommend that
subtyping is based on the choice of partners associated with the strip-club venues are a distinct and prevalent behavioral
promiscuous behavior and may not be consistent with the pro- outlet for adult entertainment as well as a distinct clinical
fessed or historically apparent sexual orientation of the person manifestation of hypersexual behavior.
affected by a Hypersexual Disorder. As typical examples, this Several of the aforementioned subtypes and their relative
class of behaviors included ‘‘one night stands,’’ repetitive hir- prevalence have been reported by other clinicians working
ing of prostitutes or escort services, serial sexual affairs, repeti- with presumptive Hypersexual Disorder. In a clinical sample
tive casual sexual encounters in massage parlors, gay cruising derived from a survey of 43 clinician members of the German
areas, and pick-up bars. Sexual behaviors associated with Society of Sex Research (Briken et al., 2007), 97 persons
the Hypersexual Disorder (Sexual Behavior with Consenting (males = 78; females = 19) seeking help for hypersexual
Adults) typically included vaginal or anal sexual intercourse, behaviors (identified as paraphilia-related disorders) were
oral sex or mutual masturbation. This common Hypersexual described. In the predominantly male sample, the three most
Disorder was identified in 50% of males seeking treatment for prevalent paraphilia-related disorders were pornography
PAs and PRDs (Kafka & Hennen, 1999). Heterosexual promis- dependence (48.7%), compulsive masturbation (34.6%), and
cuity was significantly associated with telephone sex depen- protracted promiscuity (20.5%).
dence. Reid, Carpenter, and Lloyd (2009) reported on 59 males
Severe sexual desire incompatibility had a 12% sample seeking specialized clinical treatment for hypersexual behav-
prevalence (Kafka & Hennen, 1999) and, by definition, was iors. Self-reported problematic sexual behaviors included com-
associated with pair-bond dysfunction or disruption. Severe pulsive masturbation (56%), pornography dependence (51%),
sexual desire incompatibility was specifically defined such and 39% for various combined subtypes of sexual behavior
that the partner who was affected by their spouse’s hyper- with consenting adults: habitual solicitation of commercial sex
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388 Arch Sex Behav (2010) 39:377–400
workers (7%), extra-marital affairs (21%), and excessive unpro- complex diagnosis to establish. Last, data on women with
tected sex with multiple anonymous partners (12%). Hypersexual Disorder are lacking although protracted pro-
miscuous behavior has been reported by contemporary inves-
tigators and noted historically as nymphomania.
Females and Hypersexual Disorder The clear behavioral distinctions between the specifiers
involved in Hypersexual Disorder gives these differing spe-
The frequency distribution of specific Hypersexual Disorder cifiers face validity although it would not be uncommon for
in females has been inadequately studied. In both clinically specifiers to co-occur together (e.g., pornography and mastur-
derived as well as population-based studies, males substan- bation) or to accrue over a longer period of time (e.g., cyber-
tially outnumber females with these conditions. In Black sex, masturbation, sexual behavior with consenting adults).
et al.’s (1997) sample of 36 self-identified sexually compul- Inasmuch as there has not yet been established a uniform meth-
sive men and women, 8 were female (22%). Carnes and odology to diagnostically assess Hypersexual Disorder, the
Delmonico (1996), drawing from a self-selected sample of inter-rater reliability of various investigators asserting such
290 sex addicts, reported that 20% (n = 58) were females. In specifiers has not yet been adequately tested.
the small female sample (n = 19; 19.5% of their sample of 97
patients) reported by German sexological clinicians, pro-
tracted promiscuity, compulsive masturbation, and cyber- Hypersexual Disorder: Clinically Significant Distress
sex have been documented in women seeking treatment for or Impairment in Social, Occupational or Other
Hypersexual Disorder (Briken et al., 2007). Winters et al. Important Areas of Functioning
(2009) reported on 69 women (0.8% of their sample) who
sought treatment for sexual compulsivity but the specific Many investigators have noted that Hypersexual Disorder is
behaviors that were disordered were not reported. Långström associated with or in response to dysphoric affects (Black
and Hansen’s (2006) epidemiological data verified that et al., 1997; Raymond et al., 2003; Reid, 2007; Reid et al.,
multiple hypersexual behaviors were reported by a sub- 2008, 2009) or stressful life events (Miner et al., 2007; Nelson
stantial minority (6.8%) of females. Although a history of & Oehlert, 2008). Volitional impairment has also been
sexual abuse is more commonly associated with adult sexual noted by Coleman (1987), Carnes (1989), Bancroft and
dysfunction, sexual abuse may be associated with hyper- Vukadinovic (2004), and Miner et al. (2007). Sexual preoc-
sexual behaviors in a subgroup of affected adult females cupation has been assessed and noted as a significant concom-
(Långström & Hanson, 2006; Rellini, 2008). itant by Kalichman and Rompa (1995), Kafka (1997b; 2003a),
Ross (1996) reported on a self-selected sample of 18 female Kalichman and Cain (2004), and McBride et al. (2008).
sex addicts. The most common sexual addictions, co-equally McBride et al. (2008) have reported adequate psycho-
affecting about 90% of the sample, included fantasy sex, seduc- metric properties of the Cognitive and Behavioral Outcomes
tive role sex, voyeuristic sex, and anonymous sex. The lack of of Sexual Behavior (CBOSB) scale as a means to assess legal,
empirical research and systematic clinical data on females with occupational, psychological/spiritual, social, physical, and
Hypersexual Disorder is a major limitation of the current state financial consequences associated with sexual compulsivity
of scientific knowledge of how these conditions afflict women. (as assessed by the Sexual Compulsivity Scale). They tested
their scale in a college sample of 390 young adults (women;
Summary n = 274: men = 116) and co-administered the SCS to assess
sexual risk-taking behaviors. Although the CBOSB was pri-
There is adequate empirical evidence for several specifiers marily used to assess consequences associated with engag-
(non-exclusive subtypes) for Hypersexual Disorder. Mastur- ing in frequent risk-taking partnered sex (unprotected sexual
bation, pornography, sexual behavior with consenting adults intercourse, anal intercourse), this instrument in conjunction
(protracted promiscuity), and cybersex can become persis- with the SCS demonstrated promise as a means to system-
tent disordered behaviors with significant adverse conse- atically assess the adverse consequences associated with
quences that have been reported by multiple investigators. Hypersexual Disorder.
There is less confirmatory evidence, however, for telephone Muench et al. (2007) reported the reliability and validity of
sex, strip clubs, and severe sexual desire incompatibility. a 21-item Compulsive Sexual Behavior Consequences Scale
While there is no doubt that severe sexual desire incompat- in a group of 34 homosexual and bisexual males enrolled in
ibility exists as a clinical entity, it is a ‘‘relationship’’-depen- a medication trial testing the efficacy of a serotonin reup-
dent disorder. Establishing a clear boundary differentiat- take inhibitor (citalopram) in reducing hypersexual behaviors
ing between a partner with a low sexual interest or a partner (primarily promiscuity). Although their sample population
who may develop a sexual dysfunction in response to their was small, their scale ascertained significant intrapersonal
hypersexual partner’s persistent sexual proclivity make this a consequences (e.g., depressed, anxious, guilt shame, loss of
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interest in other activities), interpersonal consequences (e.g., their clinical sample to a control group of 54 college age men.
harm to intimate relationships, failure to meet commitments, The hypersexual sample reported more interpersonal sensi-
risk-taking impulsivity, sex outside of a relationship), and tivity/depressive (neuroticism) symptoms, obsessive charac-
medical consequences (e.g., harm to physical health) associ- teristics, social alienation, and preoccupation than the sample
ated with their studied population. norms of the scale.
The most serious medical morbidity and mortality asso- Briken et al. (2007) ascertained ICD-10 defined Axis I
ciated with protracted sexual promiscuity (specifier: sexual psychiatric diagnoses from a sample of 97 patients (males;
relations with consenting adults) is the transmission of sexual n = 78: females; n = 19) reported by survey from clinician
transmitted diseases, including HIV infection (Kalichman & members of the German Society of Sex Research. The most
Cain, 2004; Kalichman, Kelly et al., 1997) and unintended common group of conditions was ‘‘neurotic disorders’’
pregnancy (Henshaw, 1998). Higher scores on the SCS pre- reported in 73.7% of females and 26.9% of males. Thirty-six
dicted engaging in sex with more partners and greater risk percent of the females also reported an eating disorder and
taking behavior associated with sexual behavior (e.g., less 19.6% of the males reported a lifetime sexual dysfunction.
condom use, anal sex, acquisition of sexually transmitted dis- In studies that systematically evaluated Axis I psychiat-
eases) (Dodge et al., 2004, 2008; Kalichman & Cain, 2004; ric diagnoses in ‘‘sexually compulsive’’ males and females
Kalichman & Rompa, 1995, 2001). Protracted promiscuity (Black et al., 1997; Raymond et al., 2003) or males with
was associated with continued high-risk sexual behavior paraphilia-related disorders (Kafka & Hennen, 2002; Kafka
in HIV positive men and women (Benotsch, Kalichman, & & Prentky, 1994, 1998), one of the consistent findings was
Pinkerton, 2001). Individuals with higher SCS scores also that the great majority of subjects with these disorders have
reported a higher incidence of unprotected vaginal and anal multiple lifetime comorbid mood, anxiety, psychoactive
intercourse, more sexual partners, higher rates of drug use, substance abuse, and/or other impulse disorder diagnoses.
and more psychopathology. In 36 male (n = 28) and female (n = 8) participants to an
advertisement for‘‘compulsive sexual behavior,’’Black et al.
(1997) administered the Diagnostic Interview Schedule for
Summary
DSM-III-R disorders (Axis I) and the Structured Interview
for DSM-III-R Personality Disorders, Revised (Axis II). The
There is ample evidence reported from multiple investigators
Axis I disorders reported included a lifetime prevalence of
that Hypersexual Disorder is associated with clinically signifi-
any psychoactive substance abuse (64%, primarily alcohol
cant personal distress and serious adverse consequences, includ-
abuse), any anxiety disorder (50%, especially phobic disor-
ing increased risk of sexually transmitted diseases, unwanted
ders), any mood disorder (39%, major depression and dys-
pregnancies, severe pair-bond impairments, excessive finan-
thymia), and an unspecified but significant total incidence of
cial expenses, work or educational role impairment and other
impulse control disorders, including compulsive buying.
associated morbidities. In addition, there are several rating
Lifetime OCD was reported by 14% of that sample. Eighty-
instruments that may help to assess the behavioral and psy-
three percent of the sample had at least one lifetime Axis I
chosocial consequences associated with these disorders.
comorbid diagnosis.
Raymond et al. (2003) assessed current and lifetime Axis I
comorbidity utilizing the Structured Clinical Interview for
Hypersexual Disorder and Associated Features: DSM-III-R-patient version in a sample of 25 participants (23
Axis I Comorbidity males, 2 females) to a newspaper advertisement soliciting
persons with compulsive/addictive sexual behaviors. They
Rinehart and McCabe (1998) administered a series of vali- administered the Compulsive Sexual Behavior Inventory to
dated rating scales assessing anxiety, depression, obsessive– assess the severity of sexually compulsive behaviors. Axis I
compulsive symptoms, and impulsivity to a non-clinical lifetime comorbidity was 100%. The most common class of
group of male (n = 69) and female (n = 93) university stu- disorders was any anxiety disorder (96%), especially social
dents. The students were divided into two groups based phobia (21%) and generalized anxiety disorder (17%). Any
on their self-reported frequency of 12 different sexual behav- substance abuse disorder (71%), especially alcohol (63%)
ior variables, including both paraphilic and nonparaphilic and cannabis (38%), and any mood disorder (71%) especially
behaviors. The nonparaphilic hypersexual group did not dif- major depression (58%), dysthymia (8%), and bipolar dis-
fer in the aforementioned traits in comparison with the low order (8%), were the second most prevalent classes of Axis I
frequency sexual behavior group. psychiatric disorders. Lifetime sexual dysfunctions were sur-
In contrast to Rinehart and McCabe, Reid et al. (2009) prisingly common (46%), especially male erectile dysfunc-
administered the SCL-90 to 59 males seeking psychological tion (23%). Last, any impulse control disorder (38%), espe-
help for nonparaphilic hypersexual behaviors and compared cially kleptomania (13%) and intermittent explosive disorder
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390 Arch Sex Behav (2010) 39:377–400
(13%), were diagnosed. Their sample endorsed both impul- (1997) solicited 36 participants (28 males, 8 females) and
sive and compulsive traits but the sample prevalence of reported that 44% of their sample had an Axis II diagnosis, the
lifetime OCD was modest (8%). most common being cluster B (29%) and cluster C (24%).
Kafka and Hennen (2002) and Kafka and Prentky (1994, The prevalence of specific Axis II disorders was histrionic
1998), in three outpatient males samples (total n = 240), (21%), paranoid and obsessive compulsive (both 15%), and
reported that the typical male with PRDs without PAs had passive aggressive (12%). In both of the aforementioned stud-
multiple lifetime Axis I disorders, including any mood disor- ies, antisocial personality disorder and borderline personality
der (61–65%, especially dysthymic disorder), any psychoac- disorder, personality disorders specifically associated with
tive substance abuse (39–47%, especially alcohol abuse), any impulsivity, had a low prevalence.
anxiety disorder (43–46%, especially social phobia), attention
deficit hyperactivity disorder (17–19%), and any impulse con- Summary
trol disorder (7–17%), especially the atypical impulse control
disorder reckless driving. Lifetime comorbidity with obses- Axis I psychiatric diagnoses, especially mood disorders, anxi-
sive–compulsive disorder was low (0–11%) in all three ety disorders, psychoactive substance abuse disorders, and
reports. It is of clinical interest that males with PRDS did not attention deficit hyperactivity disorders have been reported
statistically significantly differ from males with PAs in the to be prevalent among males with Hypersexual Disorder.
lifetime prevalence of mood, anxiety, psychoactive substance The various putative pathophysiological models previously
abuse, or impulse control disorders. Between 85 and 90 per- reviewed describing normophilic hypersexual behaviors all
cent of the samples met lifetime diagnostic criteria for at least include the observation that hypersexual behaviors are typi-
one non-sexual comorbid Axis I disorder. In the second and cally associated with dysphoric affects, such as anxious or
third reports (Kafka & Hennen, 2002; Kafka & Prentky, 1998), depressive mood, irritability, and boredom. Risk-taking and
however, the addition of the retrospective assessment of atten- sensation seeking can be associated with unipolar and bipolar
tion deficit hyperactivity disorder (ADHD) did statistically mood disorders as well as ADHD. These observations are
distinguish the PA (prevalence of ADHD was 36–50%) from consistent with the data reviewed that Axis I psychiatric dis-
the PRD group (17–19%). It was also reported that the inat- orders, especially mood disorders, anxiety disorders, and
tentive subtype of ADHD was predominant in PRD males ADHD have been identified in persons afflicted with these
while ADHD-combined subtype was more prevalent in para- disorders. On the other hand, clearly not all persons affected by
philic men. the aforementioned Axis I co-morbidities developed hyper-
Although I could not find a systematic study of Axis I sexual behaviors or Hypersexual Disorder.
disorders in the sexual addiction literature, ADHD-inatten- Mood disorders, in particular, are associated with dys-
tive subtype was identified as a comorbid psychiatric in regulation (either an increase or a decrease) of sleep and
sexual addicts (Blankenship & Laaser, 2004) as well as 67 appetite. Although a decrease in sexual interest and enacted
males seeking help for hypersexual behavior disorders (Reid, sexual behavior can be associated with major depression
2007). Several articles have reported depression (Blanchard, (Williams & Reynolds, 2006), increased sexual behavior has
1990; Turner, 1990; Weiss, 2004) in recovering sex addicts. been noted in association with depressive disorders as well
(Mathew, Largen, & Claghorn, 1979; Mathew & Weinman,
1982). In DSM-IV-TR, hypomanic episodes can be associ-
Hypersexual Disorder and Associated Features: Axis II ated with‘‘sexual indiscretions,’’including promiscuous behav-
Comorbidity ior and‘‘increased sex drive, fantasies and behavior.’’Recent
data from community samples reporting that the mean dura-
Two studies with adequate methodology solicited males tion of hypomanic episodes may be significantly less than 4 or
and females with‘‘compulsive sexual behaviors’’from news- more days (Benazzi, 2001; Judd & Akiskal, 2003), the cur-
paper advertisements and administered the Structured Inter- rent DSM-based duration criteria for Bipolar II further
view for DSM-III-R Personality Disorders, Revised. In complicates establishing a clear boundary between an illness
assessing current Axis II diagnoses, Raymond et al. (2003) ‘‘episode’’ and a recurrent sexual behavior that could be
reported that 46% of the sample (n = 24, 22 males, 2 females) associated with risk-taking and adverse consequences.
met criteria for at least one personality disorder, the most
common being cluster C disorders (39%) followed by cluster
B (23%) personality disorders. The current prevalence of five Hypersexual Disorder: Placement in the Nomenclature
most common personality disorders was as follows: paranoid
(20%), passive aggressive (20%), narcissistic (18%), avoid- As is evident from this review, there are differing perspec-
ant (15%), and obsessive–compulsive (15%). Black et al. tives on the putative pathophysiological substrates for Hyper-
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sexual Disorder. There are data to support conceptualizing Sexual Addiction or Impulsive–Compulsive Sexual
Hypersexual Disorder as a sexual desire disorder, a disorder Behavior
with an admixture of both compulsive and impulsive features,
or a behavioral addiction. Inasmuch as we do not have the The designation of nonparaphilic sexual behavior disorders
neurobiological/neuropsychological data to more definitively as a behavioral addiction or admixture of compulsive/impul-
assess the etiology for this set of sexual behavior disorders, sive behavior merits further study. Several criteria proposed
controversy will likely continue as to what DSM-based for Hypersexual Disorder are consistent with a behavioral
‘‘category’’ is the best fit for Hypersexual Disorder. At this addiction model as applied to the impulsity-associated com-
point, the empirical evidence suggests that persons afflicted ponent of Hypersexual Disorder. Examining a larger and
with Hypersexual Disorder are heterogeneous and the clinical community-based sample of men and women who could be
course associated with these conditions may have differing solicited by advertisement or survey methodology, identified
presentations and characteristics precedent to adverse con- as having problematic sexual behaviors, and then applying the
sequences and help-seeking behavior. For these reasons, an full criteria for psychoactive substance abuse modified to
operational definition for Hypersexual Disorder that can diagnose behavioral excesses of sexual behaviors would be
incorporate dimensions that are most common across dif- very helpful in clarifying the comparative prevalence of sex-
fering clinical samples would be most beneficial to further ual addiction/dependence among men and women reporting
improve the identification of this significant sexual disorder. both paraphilic and nonparaphilic hypersexual behaviors.
Such a definition that combines empirically validated criteria In addition, neuropsychological studies and neuroimaging
from the aforementioned putative models is incorporated into studies of males and females with Hypersexual Disorder are
the operational definition for Hypersexual Disorder presented needed to delineate whether there are common pathways
in the review. that are associated with these disorders and other behavioral
addictions or impulsivity disorders. At present, the published
Sexual Compulsivity and the OCD-Spectrum literature is lacking to firmly support a specific‘‘withdrawal’’
state associated with the abrupt cessation of Hypersexual
The theoretical construct of ‘‘compulsive sexual behavior’’ Behavior. I also did not find sufficient empirical evidence of
as associated with an OCD-spectrum is not empirically sup- ‘‘tolerance’’ although progressive risk-taking in association
ported by the Axis I or Axis II comorbidity reports reviewed in with hypersexual behaviors could be analogous to drug tol-
this report. The comorbid occurrence of OCD in males with erance. This is not to state that withdrawal and tolerance do not
Hypersexual Disorder is modest at best (0–12%) based on the exist in hypersexual conditions but, rather, that further studies
aforementioned reports. In addition, Jaisoorya, Reddy, and are necessary to support their clinical presence and relevance.
Srinath (2003) reported that the incidence of sexual compul- Normal sexual behavior in humans is characterized by
sivity in 168 males with DSM-IV-defined OCD in comparison sexual fantasies, urges, and activities. Similar endogenously
with 148 males controls was not statistically significant. In derived and motivated ‘‘drive’’ behaviors include eating,
DSM-III through DSM-IV-TR, it has been specifically noted thirst, and sleep. These biologically based appetites are nec-
in discussing the differential diagnosis of Obsessive–Com- essary for survival of the species. The placement of Hyper-
pulsive Disorders: sexual Disorder as Impulsivity Disorders in DSM-V would
beg the question of whether a behavioral addiction/impul-
Some activities, such as eating, sexual behavior (e.g.,
sivity model should also be applied to other excesses of human
paraphilias), gambling, or drinking, when engaged in
appetitive behaviors that have a biological substrate and are
excessively may be referred to as ‘‘compulsive.’’ How-
necessary for species survival. The most obvious examples
ever, these activities are not true compulsions, because
are the eating disorders (Goodman, 2008). If hypersexual
the individual derives pleasure from the particular activ-
behavior (or overeating) is a behavioral addiction or depen-
ity and may wish to resist it only because of its secondary
dency syndrome, do some persons with Hypersomnia have a
deleterious consequences. (American Psychiatric Asso-
sleep addiction or sleep ‘‘dependence’’ syndrome when they
ciation, 2000, pp. 461–462)
sleep excessively, miss important social or personal responsi-
Based on all of these data, describing a class of sexual bilities, and view their sleep as a pleasurable means of escape
behavior disorders as ‘‘compulsive’’ has some historical and from psychological stress or depression? As currently for-
clinical utility but this designation is not consistent with mulated, none of the DSM-IV-TR Impulsivity Not Otherwise
DSM-derived nomenclature to identify a new diagnostic Specified Disorders specifically include sleep, thirst, eating or
category for a sexual disorder. sexual behaviors.
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392 Arch Sex Behav (2010) 39:377–400
Sexual Disorders and Sexual Desire Disorders ulated male:female prevalence ratio of Hypersexual Disorder,
estimated at 5:1 (Black et al., 1997; Carnes & Delmonico,
Sexual preference, sexual fantasy, sexual arousal, sexual 1996; Schneider & Schneider, 1996) is not a high as the esti-
motivation and overt sexual behaviors are each important mated ratio for paraphilias (20:1) (American Psychiatric Asso-
components of normal human sexuality as well as Paraphilic ciation, 1987, 1994), Hypersexual Disorder is nonetheless pre-
Disorders, Hypersexual Disorder and Hypoactive Sexual dominantly a male disorder. Second, clinical populations of
Desire Disorder. Persons with normophilic sexual preferences PAs and Hypersexual Disorder both report the onset of inten-
and hypersexual behaviors may have long periods (e.g., dec- sified or unconventional sexual arousal during adolescence
ades) of waxing and waning or persistent increased sexual (Abel, Becker, Cunningham-Rathner, Mittelman, & Rouleau,
appetitive behaviors preceding help-seeking behavior (Kafka, 1988; Abel, Mittleman, & Becker, 1985; Black et al., 1997;
1997b; Långström & Hanson, 2006). Kafka, 1997b). Third, several empirical studies have reported
It is certainly possible that during the clinical course asso- that persons presenting for clinical treatment for PAs (Abel
ciated with a particular sexual behavior evolving into a Hyper- et al., 1988; Buhrich & Beaumont, 1981; Freund, Sher, &
sexual Disorder, the internal state of motivation associated Hucker, 1983) or Hypersexual Disorder (Carnes, 1983, 1989,
with such behavior may shift from primarily sexual arousal 1991a; Kafka & Hennen, 1999) commonly self-report the
associated with youthfulness to an admixture of sexual arousal, presence of multiple rather than a single paraphilic or hyper-
sexual motivation and a maladaptive behavioral response sexual behavior over the course of a lifetime. These studies
associated with a dimensional measure of volitional impair- suggests that there is a general diathesis or vulnerability for
ment: impulsivity, compulsivity or behavioral addiction (Ban- both PAs and/or Hypersexual Disorder. Fourth, in both sets
croft & Vukadinovic, 2004; Bancroft et al., 2003b, c; Carnes, of Sexual Disorders, sexually arousing fantasies, urges, and
1983; Coleman, 1987). To label the problematic presentation behaviors can be time consuming or associated with sexual pre-
of such behaviors as primarily an impulse control disorder, occupation (Black et al., 1997; Carnes, 1983; Kafka, 1997b).
impulsive–compulsive spectrum disorder or behavioral addic- Fifth, analogous to paraphilias (American Psychiatric Asso-
tion may help to account for an important feature of the mor- ciation, 2000), Hypersexual Disorder may wax and wane, be
bidity-associated end product of Hypersexual Disorder. The either ego-syntonic or ego-dystonic, and are more likely to
specific characterization of the impulsivity associated with occur or intensify during periods of‘‘stress’’(Black et al., 1997).
Hypersexual Disorder however, does not address the norm- Sixth, males with PAs as well as Hypersexual Disorder are
ophilic sexual preferences and lengthy prodromal increase in equally likely to self-report periods of persistently height-
fantasies sexual urges and behaviors that precede the accu- ened sexual behaviors leading to orgasm in comparison to pop-
mulation of adverse consequences. These components of ulation norms (Kafka, 1997b; Kafka & Hennen, 2003). Last, as
Hypersexual Disorder are more consistent with a Sexual is the case for PA disorders, many persons with Hypersexual
Desire Disorder. I am suggesting that conceptually, Hypoac- Disorder may withdraw from sexual encounters with a partner
tive Sexual Desire Disorder and Hypersexual Disorder repre- in preference to engage in unconventional sexual activities that
sent the opposite polarities in the frequency distribution of become more sexually arousing than‘‘ordinary’’sex. This may
sexual appetitive behavior, including sexual arousal and sex- promote extramarital encounters, reliance on masturbation-
ual motivation. associated sexual outlets, and/or pair-bond dysfunction.
It is the proposal of this author and the Paraphilias subwork-
group that Hypersexual Disorder be considered in DSM-V as
Differential Diagnosis of Hypersexual Disorder: distinct from paraphilias although these two sets of disorders
Hypersexual Disorder and Paraphilias can be comorbidly associated and a paraphilic interest can be
expressed in association with specific hypersexual behaviors.
Paraphilias are characterized by socially anomalous or‘‘devi- Many studies of paraphilic sex offenders do not systematically
ant’’forms of sexual preference and sexual arousal (e.g., pedo- assess Hypersexual Disorder; nevertheless, Hypersexual Dis-
philia, fetishism, exhibitionism) while Hypersexual Disorder order may be common among PA males (Anthony & Hol-
is a disinhibited or excessive appetitive expressions of cultur- lander, 1993; Black et al., 1997; Breitner, 1973; Briken, Haber-
ally adapted normophilic sexual behaviors. Both sets of condi- mann, Kafka, Berner, & Hill, 2006; Gagné, 1981; Kafka,
tions, however, are associated with intense and repetitive, sex- 2003a; Kafka & Hennen, 1999, 2002; Kafka & Prentky, 1998;
ually arousing fantasies, sexual urges, and behaviors (Crite- Langevin et al., 1985; Levine, Risen, & Althof, 1990; Longo
rion A), a minimum duration of 6 months (Criterion A), and & Groth, 1983; Prentky et al., 1989; Travin, 1995). For exam-
marked personal distress or indications of significant psy- ple, extensive and persistent pornography use, along with
chosocial impairment (Criterion B) related to sexual behavior. other empirically based risk factors, is associated with sexual
Hypersexual Disorder shares many other common clinical aggression against adult females (Knight & Cerce, 1999;
characteristics of paraphilic disorders. First, although the spec- Malamuth, Addison, & Koss, 2000) as well as children
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Arch Sex Behav (2010) 39:377–400 393
(Kingston, Fedoroff, Firestone, Curry, & Bradford, 2008). Medical Condition (American Psychiatric Association, 2000;
In some instances, the predominant content of pornography Stein, Hugo, Oosthuizen, Hawkridge, & van Heerden, 2000)
may reflect a paraphilic disorder (e.g., diagnosed as pedo- would be coded if such behaviors did not meet the full
philia or sexual sadism) but the extensive or ‘‘heavy’’ per- Hypersexual Disorder diagnostic criteria. The general med-
sistent and problematic use pornography associated with ical or neurological condition would then be noted on both
compulsive masturbation would presumably be most con- Axis I and Axis III (American Psychiatric Association, 2000).
sistent with a Hypersexual Disorder (pornography and mas- The only codified‘‘medical’’exclusion for Hypersexual Dis-
turbation) as intended for DSM-V. In some instances, it could order (Criterion C) would be when a sexual behavioral con-
be possible that a male apprehended for possession of child dition was clearly and exclusively associated with a specific
pornography could have a primary Hypersexual Disorder medication or drug effect. In that instance, Substance-
(pornography) without concomitant pedophilia if it could be Induced Hypersexual Disorder or Hypersexual Behavior
demonstrated that his pornography viewing, collecting or should be coded (Stein, Hugo et al., 2000).
laboratory assessed sexual arousal preference was for adults
or that child pornography, while illegal, was not predominant Summary
or enduring in his collection.
Cybersex chat rooms have been venues for some pedo- Hypersexual Disorder has been primarily characterized as
philes or hebephiles to meet and groom possible victims compulsive, impulsive, a behavioral addiction or a sexual
through this medium (Nordland & Bartholet, 2001). Such a desire disorder. Regarding the possible categorical place-
male, if apprehended by legal authorities, would be diag- ment in DSM-V, this author suggests that the term ‘‘com-
nosed with pedophilia (or pedohebephilia as is proposed for pulsive,’’while apt in describing features of these conditions,
DSM-V; see Blanchard, 2009) if durational criteria are met is not consistent with prior DSM-based conceptualization of
for the former diagnosis and Hypersexual Disorder (cyber- an obsessive–compulsive spectrum disorder. The categori-
sex) as well. On the other hand, a man or woman who sought zation of Hypersexual Disorder as an impulsive–compulsive
professional help for time consuming cybersex activity asso- disorder or behavioral addiction in DSM-V could be feasible
ciated with compulsive masturbation and repetitive promis- but more data are needed to justify such a designation. In
cuous behavior with peers could be diagnosed with Hyper- addition, the designation of Hypersexual Disorder as primary
sexual Disorder (cybersex, sexual behavior with consenting an Impulsivity Disorder could contradict the current place-
adults or masturbation). ment of other putatively analogous, biologically mediated
appetitive behaviors disorders such as Bulimia Nervosa
(Eating Disorders) or Hypersomnia (Sleep Disorders). As
Hypersexual Disorder Associated with Neuropsychiatric previously stated, it is my opinion, based on the literature
Illness, Neurodegenerative Conditions, reviewed, that Hypersexual Disorder be considered as a
and Drug-Induced Conditions Sexual Disorder associated with increased or disinhibited
expressions of sexual arousal and desire in association with a
The term ‘‘hypersexuality’’ has also been utilized to describe dimension of impulsivity as well.
acute changes in sexual behavior, usually induced by a neu- Paraphilias, characterized by socially unconventional or
ropsychiatric illness (Blumer, 1970; Huws, Shubsachs, & social ‘‘deviant’’ sexual arousal, are distinct from Hypersex-
Taylor, 1991; Jensen, 1989; Krueger & Kaplan, 2000; Tosto, ual Disorder although both of these sexual disorders can co-
Talarico, Lenzi, & Bruno, 2008; Van Reeth, Dierkins, & occur. As noted above, in some instances paraphilic interests
Luminet, 1958), brain injury (Epstein, 1973; Miller, Cum- and arousal can be incorporated in hypersexual behaviors
mings, & McIntyre, 1986; Monga, Monga, Raina, & Hardja- and, in those circumstances, both conditions could be diag-
sudarma, 1986; Zencius, Wesolowski, Burke, & Hough, 1990), nosed. Hypersexual behaviors, as well as paraphilic behav-
or a medication effect typically induced by dopaminergic iors, can be associated with medical and neurological con-
agonists (Bilgiç, Gürkan, & Türkoğlu, 2007; Boffum, Moser, & ditions. To maintain diagnostic clarity, it is recommended
Smith, 1988; Uitti, Tanner, & Rajput, 1989; Vogel & Schiffter, that Hypersexual Disorder be diagnosed if durational and
1983). In these circumstances, it is not unusual for disinhibited diagnostic criteria are met in such circumstances. Hyper-
hypersexual behaviors to be an admixture of normophilic and sexual Behavior Due to a General Medical Condition would
paraphilic-like sexual behaviors (e.g., inappropriate touching be diagnosed if the full Hypersexual Disorder criteria are not
and exposing one’s genitals but not to strangers). met or able to be ascertained. Substance-Induced Hyper-
Persistent hypersexual behaviors secondary to neuropsy- sexual Disorder would be considered an as appropriate diag-
chiatric, medical illness or brain injury could be codified nostic designation when it is evident that there is a direct and
as Hypersexual Disorder as long as it fulfills the diagnostic specific causal effect between medications or substances of
A and B criteria. Hypersexual Behavior Due to a General abuse and disinhibited sexual behavior. If full diagnostic
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394 Arch Sex Behav (2010) 39:377–400
criteria for Hypersexual Disorder were not achieved, a diag- Janssen, 2000; Bancroft et al., 2003a) was able to discrimi-
nosis of Substance-Induced Hypersexual Behavior would be nate a small sample of hypersexual men and women from a
recommended. control group (Bancroft & Vukadinovic, 2004). Such dimen-
sional measures can help to assess the severity or morbidity
associated with diagnostic categories have been emphasized
Conclusion for DSM-V (Kraemer, 2007). Of the available rating scales
that I reviewed, the SCS, the SIS-II and SES, and the CSBI
In past proposals to include disinhibited or excessive non- have the strongest empirical reliability and validity. It is note-
paraphilic sexual behaviors as a distinct diagnostic category worthy, however, that none of these aforementioned scales
of sexual addiction for the DSM, it has been argued that there embody the specific diagnostic criteria proposed for Hyper-
were ‘‘insufficient data’’ (Gold & Heffner, 1998; Wise & sexual Disorder. Nevertheless, it would be most helpful if
Schmidt, 1997) and these conditions have been relegated to any proposed diagnostic criteria or dimensional measure for
Sexual Disorders Not Otherwise Specified. Hypersexual Disorder could be compared with these scales
It must be noted, on the basis of this current review, that the as a dimensional measures of severity.
number of ‘‘cases’’ of Hypersexual Disorder reported in peer- There are significant gaps in the current scientific knowl-
reviewed journals greatly exceeds the number of cases of some edge base regarding the clinical course, developmental risk
of the codified paraphilic disorders such as Fetishism and factors, family history, neurobiology, and neuropsychology
Frotteurism. Hypersexual Disorder, as operationally defined in of Hypersexual Disorder. Empirically based knowledge of
this review, is not synonymous with sexual addiction, sexual Hypersexual Disorder in females is lacking in particular. As
compulsivity or paraphilia-related disorder but all of these is true of so many psychiatric disorders, the comment that
aforementioned designations describe increased and intensi- ‘‘more research is needed’’ is certainly applicable to these
fied sexual fantasies, urges, and behaviors with significant conditions. Although these are significant shortcomings in
adverse personal and social consequences. Hypersexual Dis- the state of our current empirical knowledge, there is little
order is a serious and common clinical condition that can be doubt that such conditions commonly present to clinicians
associated with specific morbidities, such as unplanned preg- as well as specialized treatment programs.
nancy, pair-bond dysfunction, marital separation and divorce,
and the morbidity/mortality risk associated with sexually Acknowledgments The author is a member of the DSM-V Workgroup
on Sexual and Gender Identity Disorders (Chair, Kenneth J. Zucker,
transmitted diseases including HIV. Ph.D.). I wish to acknowledge the valuable input I received from members
There will always be controversy when any class of behav- of my Paraphilias subworkgroup (Ray Blanchard, Richard Krueger, and
iors, including sexual behaviors, that are intrinsically ‘‘nor- Niklas Långström), Kenneth J. Zucker, and two Workgroup Advisors,
mal’’ are medically ‘‘pathologized’’ (Money, 1994). Indeed, David Delmonico and Michael Miner. Reprinted with permission from
the Diagnostic and Statistical Manual of Mental Disorders V Workgroup
there have been calls for the Paraphilic Disorders to be Reports (Copyright 2009), American Psychiatric Association.
removed from diagnostic codification as well based on insuf-
ficient data and diagnosis-associated social stigmatization
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DOI 10.1007/s10508-009-9575-6
ORIGINAL PAPER
Dimensional Measurement of Sexual Deviance

R. Karl Hanson

Abstract There are at least three approaches by which psy- difficulties with categorical descriptions of human behavior
chopathology can be described in terms of dimensions. Each (Brown & Barlow, 2009; Maser et al., 2009; Slade, Grove, &
approach involves counting the number and severity of symp- Teesson, 2009). Categories are justified to the extent that (1)
toms, but these scores have distinct meanings based on symptoms are organized in distinct and predictable patterns,
whether the latent construct is considered to be categorical or (2) the antecedents and course of the disorder are distinctive
dimensional. Given a categorical construct, dimensions can and predictable, (3) the symptom pattern is linked to a theo-
index either diagnostic certainty or symptom severity. For retically coherent account of their development, expression,
inherently dimensional constructs, the severity of the symptoms and course, and (4) changes in the severity of the disorder can
is essentially isomorphic with the underlying latent dimension. be observed by deliberate manipulation of the causal factors
The optimal number of dimensions for describing paraphilias is articulated in the theoretical model. The final criterion is nec-
not known, but would likely include features related to prob- essary to distinguish syndromes or symptom patterns that are
lems in sexual self-regulation, the diversity of paraphilic inter- purely descriptive from identifiable disorders that are respon-
ests, and the overall intensity of sexual drive and expression. sible for causing the symptoms.
Complex measures of these (and related) dimensions currently None of the existing paraphilic disorders fully meet the
exist, but simplified criteria are needed for routine communi- criteria for being categorically distinct disorders. Pedophilia
cation among diverse mental health professionals. Estab- is perhaps the leading contender, given its distinctive expres-
lishing these criteria would requires professional consensus sion and predictable course (e.g., early onset, high stability;
on the nature of the latent dimensions, as well as reliable Seto, 2008). There is little consensus, however, concerning the
assessment of the core constructs using non-arbitrary scales cause of pedophilia. As well, it is common for individuals dem-
of measurement. onstrating sexual interest in children to have other paraphilic
interests (Abel, Becker, Cunningham-Rathner, Mittelman, &
Keywords Assessment Paraphilias Dimensional Rouleau, 1988; Raymond, Coleman, Ohlerking, Christenson,
measurement DSM-V & Miner, 1999). Phallometric profiles of men whose strongest
response involve children typically show substantial responses
to other age and gender categories (Lalumière & Harris, 2008).
Introduction In contrast, the profiles of typical heterosexual or homosexual
males are highly differentiated, with strong responses to adults
Psychopathology can be conceptualized both in terms of cat- of their preferred gender and little response to other categories
egories and in terms of dimensions. Most existing nosono- (Suschinsky, Lalumière, & Chivers, 2009).
mies are written in terms of categories, despite the oft-cited
Dimensionality of Psychopathology
R. K. Hanson (&)
Corrections Research, Public Safety Canada, 340 Laurier Avenue
West, Ottawa, ON K1A 0P8, Canada In order to consider dimensions of psychiatric symptoms, it is
e-mail: [email protected] necessary to first consider what these dimensions represent. I
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402 Arch Sex Behav (2010) 39:401–404
will discuss three possible meanings: (1) diagnostic confidence, criteria to determine pathology from normal; the dividing
(2) symptom strength, and (3) latent dimensions. line is determined by professional and community consensus
concerning the extent to which the behavioral patterns are
Diagnostic Confidence sufficiently extreme to be problematic. Although dimen-
sional definitions are vulnerable to criticisms of being arbi-
Even if a disorder is a true type or category, it is rare to have trary, explicit criteria usually allow evaluators to reliably
pathognomonic signs that, by themselves, determine the pres- classify most cases as problematic or non-problematic, with
ence or absence of the disorder. Instead, clinicians are required relatively few contentious cases. An example of a well-stud-
to infer the disorder from indicators, which are usually (but not ied dimensional construct would be an antisocial lifestyle,
necessarily) symptoms. One way of dimensionalizing diag- which at the extreme end is described as psychopathy (Guay,
nosis is to report the probability that the disorder is present Ruscio, Knight, & Hare, 2007).
given a particular set of indicators. For example, based on sex- It would be sensible to diagnosis dimensional constructs
ual convictions involving three unrelated boys, self-reported using both the number of different symptoms, as well as their
exclusive sexual interest in adult females, and never lived with intensity and duration. Note that, in practical terms, there is
a lover by the age of 40, an evaluator may say that the patient substantial overlap for all three conceptualization. In all three
has a 85% chance of having pedophilia (with confidence approaches, clinicians count the number of symptoms (indi-
intervals of 76 to 92%). The percentages, of course, are ficti- cators) and judge their intensity. In the first version, high num-
tious, but could be empirically established given a‘‘gold stan- bers of intense symptoms are considered to increase diagnos-
dard’’ against which to evaluate the discriminative properties tic certainty; in the second version, the symptoms are consid-
of the diagnostic indicators. An example of such an actuarial ered to measure the severity of the disorder, provided, of
approach to diagnosis is the Screening Scale for Pedophilic course, that the patient first meets a preliminary set of criteria
Interest developed by Seto and Lalumière (2001). In general, establishing that the disorder is present; in the third concep-
the more symptoms observed, the greater likelihood of the dis- tualization, the symptoms are largely isomorphic with the dis-
order being present. Note, however, that the estimated prob- order itself: patients with more extreme symptoms are con-
ability of the disorder being present is influenced by the base sidered to be worse on the latent dimensional construct than
rate of the disorder in the sample as well as by the discrimi- patients with fewer symptoms.
native properties of the indicators (i.e., Bayesian posterior
probabilities; Akobeng, 2006).
Dimensions of Sexual Deviance
Symptom Strength
Given the above considerations, I will propose three dimen-
Another sense in which diagnoses can be dimensionalized is in sions potentially relevant for the diagnosis of paraphilias: (1)
terms of symptom strength. A group of patients may all have sexual self-regulation, (2) atypical sexual interests, and (3)
the same disorder, but some may have it worse than others. As overall intensity of sexuality.
well, the severity of symptom expression may change over
time (e.g., in response to treatment). For a general discussion Sexual Self-Regulation
of dimensional measurement in DSM-V, see Helzer et al.
(2008). This conceptualization assumes two decisions: Does Sexual self-regulation could be defined as the ability to man-
the patient have the disorder? And, if so, at what level of age sexual thoughts, feelings, and behavior in a manner that is
severity? The criteria used would be different for the two deci- consistent with self-interest and that protects the rights of
sions, and evaluators would also have to consider the extent to others (minimum criteria for being ‘‘prosocial’’). The lowest
which the severity of the symptoms was related to specific levels of sexual self-regulation will involve indiscriminate,
disorders. For example, the severity of impairment from intru- disorganized sexual behavior. The next lowest level would
sive deviant sexual thoughts could be related to the severity of involve ineffective attempts to regulate sexual behavior. At
the paraphilia as well as to the severity of a co-morbid anxiety this stage, the patient would self-identify problems with sexual
disorder. behavior, which may not necessarily be seen for the most
highly disorganized cases. The positive end of the continuum
Latent Dimensions would be expressed by individuals who feel satisfied with their
sexual behavior, their behavior respects the rights of others,
There is a third sense of dimensionality that also should be and their strategies for self-control are sufficiently well devel-
considered. It is plausible that certain disorders are best oped to be perceived as effortless (no struggles). A number of
described as the extreme expressions of inherently continu- sexual self-regulation scales are available (e.g., Carnes, 1989;
ous distributions. For these disorders, there are no absolute Coleman, Miner, Ohlerking, & Raymond, 2001; Kalichman &
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Arch Sex Behav (2010) 39:401–404 403
Rompa, 1995), which include items related to self-identified able more research is needed to establish their validity and
struggles with sexual impulses, sexual activities in response to clinical utility.
negative affect, and a history of high risk sexual behavior (e.g., Given the overlap between sexual self-regulation and the
unprotected sex with prostitutes). intensity of sexual activity (Långström & Hanson, 2006), for
example, it may also be possible to combine these dimen-
sions, leaving two relevant dimensions: paraphilic interests
Atypical Sexual Interests
and sexual self-regulation. Alternately, there may be only one
dimension related to sexuality—the degree of paraphilic inter-
The second dimension is the extent of atypical sexual interests.
ests. Issues concerning sexual self-regulation may be more
Defining such interests has always been a sensitive topic, but
accurately described as part of a core dimension of low self-
there is a continuum with some individual much more likely to
control/general self-regulation.
be interested in, and to engage in, diverse sexual activities than
Identifying the most appropriate dimensional structure
others. Although most heterosexual and homosexual men are
requires professional consensus on the nature of the latent
exclusive in their sexual interests, it is quite common for those
dimensions, as well as reliable assessment of the core con-
who engage in one type of paraphilic behavior to report other
structs using non-arbitrary scales of measurement (Blanton &
paraphilic behaviors (e.g., Abel et al., 1988; Heil & English,
Jaccard, 2006; Michell, 1990). Support for distinct dimensions
2009). Consequently, it would be possible to create a dimen-
(or categories) would be provided by theoretical models artic-
sion ranging for multiple paraphilias to exclusive interest in
ulating their origins in biology and experience. As well, meta-
(‘‘normal’’) sexual behavior with consenting adults. Existing
analyses of large, empirical studies would be needed to exam-
measures that assess the diversity of sexual interests include
ine the stability of the proposed latent clusters and factors. This
the Clarke Sex History Questionnaire (Langevin & Paitich,
work is never definitive. Nevertheless, it is work worth doing.
2002) and the Wilson Sex Fantasy Questionnaire (Wilson,
1978). Acknowledgments The author is an advisor to the Paraphilias sub-
workgroup of the DSM-V Sexual and Gender Identity Disorders Work-
group (Chair, Kenneth J. Zucker, Ph.D.). This article is a revised version
Intensity of Sexuality of a commentary submitted on July 17, 2009 to the Workgroup. I would
like to thank Jobina Li for help with the references. The views expressed
Another simple dimension would be to rate the degree of are those of the author and not necessarily those of Public Safety Canada.
sexual interest and activity from ‘‘very low’’ to ‘‘very high.’’ Reprinted with permission from the Diagnostic and Statistical Manual
of Mental Disorders V Workgroup Reports (Copyright 2009), American
Although it would be possible to count orgasms (à la Kinsey), Psychiatric Association.
a better approach would be to evaluate the degree to which
sexuality consumes resources that otherwise could be devoted
to other, more productive activities (love, work, family). This
definition would also be consistent with an evolutionary model References
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risk behaviors. Journal of Personality Assessment, 65, 586–602. Seto, M. C., & Lalumière, M. L. (2001). A brief screening scale to
Lalumière, M. L., & Harris, G. T. (2008, October). What accounts for identify pedophilic interests among child molesters. Sexual Abuse:
‘penile indifference’ among sex offenders? Paper presented at the A Journal of Research and Treatment, 13, 15–25.
meeting of the Research and Treatment Conference of the Associ- Slade, T., Grove, R., & Teesson, M. (2009). A taxometric study of alcohol
ation for the Treatment of Sexual Abusers, Atlanta, GA. abuse and dependence in a general population sample: Evidence of
Langevin, R., & Paitich, D. (2002). The Clarke Sex History Questionnaire dimensional latent structure and implications for DSM-V. Addic-
for Males-Revised (SHQ-R) technical manual. Toronto: Multi- tion, 104, 742–751.
Health Systems. Suschinsky, K. D., Lalumière, M. L., & Chivers, M. L. (2009). Sex
Långström, N., & Hanson, R. K. (2006). High rates of sexual behavior in differences in patterns of genital sexual arousal: Measurement
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DOI 10.1007/s10508-009-9547-x
ORIGINAL PAPER
Coercive Paraphilic Disorder

Vernon L. Quinsey

Abstract Sexual coercion is a manifestation of sexual con- perform its natural function. A natural function is an effect that
flict that is not in itself pathological according to Wakefield’s is part of the evolutionary explanation of the existence and
(1992) criteria because sexual coercion can increase a man’s structure of the mental mechanism (the explanatory criterion).
Darwinian fitness. There are, however, differences among men From a biological point of view, pathological conditions are
in their propensity to commit rape and this propensity is linked associated with lowered Darwinian fitness.
to antisocial personality characteristics and relatively more
sexual interest in brutal rape depictions. If highly rape-prone
men were to be considered pathological, it would be possible to The Biological Context
develop diagnostic criteria to identify them.
Male and female sexual psychologies have been designed by
Keywords Rape Paraphilias Sexual coercion DSM-V relative reproductive success over evolutionary time. As in all
sexually reproducing species, however, the interests of males
and females are sometimes antagonistic because the principal
Introduction factors that limit reproductive success are different in the two
sexes. The most important (but not the only) factor limiting a
There is a long history of controversy about whether rapists man’s success is the number of his sexual partners. In contrast,
suffer from a diagnosable paraphilic disorder. In this essay, I the principal factor limiting a woman’s reproductive success is
review sexual coercion in its reproductive (evolutionary) con- the quality and amount of resources invested in her offspring.
text and consider whether coercive paraphilic disorder should be Sexual coercion is but a part of sexual conflict. Sexual con-
considered to be a diagnosable condition. flict occurs when the reproductive interests of opposite-sexed
If coercive paraphilic disorder is a diagnosable condition, individuals are opposed, in the sense that one individual’s
then it must be pathological. According to Wakefield’s (1992) success occurs at the cost of another of the opposite sex. Sex-
criteria, a person is considered to have a disorder when there is a ual conflict is widespread among animals, including species
failure of internal mechanisms to perform their natural function that exhibit social monogamy and bi-parental care. Sexual
and this failure impinges harmfully on the person’s well being as conflict ultimately arises from sexually dimorphic reproduc-
defined by social values. Thus, a condition is a mental disorder if tive strategies and can drive genetic change. Manifestations of
(1) it causes some harm or deprivation to the person as judged by sexual conflict in humans include cuckoldry and rape.
the standards of the person’s culture (the value criterion), and An evolutionary account of sexual conflict distinguishes
(2) it results from the inability of some mental mechanism to between proximal causes, the mechanisms that cause a partic-
ular characteristic in the present environment, and ultimate
causes, the features of the ancestral environment that caused an
adaptation to evolve. Proximal causation deals with mecha-
V. L. Quinsey (&)
nisms responsible for the development of characteristics in the
Department of Psychology, Queen’s University, Kingston,
ON K7L 3N6, Canada current environment, whereas ultimate causation addresses the
e-mail: [email protected] question of why these characteristics developed. Characteristics
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406 Arch Sex Behav (2010) 39:405–410
that have developed over generations because of their rela- increased at the expense of the fitness of the ‘‘losing’’ sex:
tionship to reproductive success are genetic in nature and are whatever happens to the average fitness of one sex will
termed adaptations. For example, life history strategy involves also happen to the average fitness of the other. Likewise,
a suite of adaptations and refers to a genetically organized life there cannot be a ‘‘battle’’ between males and females in
course dictating how individuals allocate energy to aspects of the sense that these two classes of individuals are striving
reproductive fitness, such as body growth, mating effort, and toward victory. In this sense, sexually antagonistic coevo-
parental effort. lution is quite different from antagonistic coevolutionary
Common errors in thinking about these matters include sup- interactions between species (e.g., parasite-host and
posing: (1) that proximal and ultimate causes are at the same predator-prey systems), because in these cases the popu-
level of explanation (i.e., are opposed to each other); (2) that lation fitness of one species can increase at the expense of
genetic causes of behavior must show heritability coefficients the other….If the sexes cannot win or lose, who can?
greater than zero (they only do if the trait shows variance in the Specific resistance and persistence alleles can. In an
population); (3) that adaptations are necessarily related to re- evolutionary sense, the dynamics of alleles most precisely
productive success in modern human environments; (4) that describes sexually antagonistic evolution. (Arnqvist &
adaptations are good for us or necessarily morally accept- Rowe, 2005, p. 221)
able; (5) that adaptations cannot be revealed by experimenta-
There are sexually dimorphic reproductive strategies in
tion, and (6) that adaptations are invariant over environmental
humans. When men are unconstrained by circumstance, they
conditions (in technical terms, are always obligate as opposed
prefer more sexual partners than women and when women are
to facultative).
unconstrained by circumstance, they prefer fewer partners
Sexual conflict between the sexes involves genes (alleles) that
than men but more resources to be invested in the relationship
confer a benefit to one sex and a cost to the other, such as a gene
and in parental assistance (e.g., Landolt, Lalumière, & Quin-
producing a wide pelvis or hirsute facial adornments. Because of
sey, 1995). Greater male than female variance in reproductive
the way genes are organized on chromosomes, genes involved in
success explains greater male mating effort, risk acceptance,
sexual conflict are often close to the sex determining genes (and
and dominance striving. As well, greater male than female
therefore travel with them to the appropriate sex most of the time
variance in reproductive success explains the differences in
in chromosomal shuffling). In order for sexually antagonistic
crime rates as a function of age and sex that are known as
genes to spread in the population, they must provide a net repro-
the fundamental data of criminology (Daly & Wilson, 1988;
ductive benefit and thus there are mechanisms for limiting the
Kanazawa, 2003; Kanazawa & Still, 2000; for an extensive
amount a particular gene is expressed in the ‘‘wrong’’ sex. These
review, see Quinsey, Skilling, Lalumière, & Craig, 2004).
mechanisms include sex limited expression where the gene is
Spectacular historical demonstrations of male reproductive
only expressed in the presence of a hormone or the amount of
success are provided by genetic studies of the patrilineages of
hormone that is typically present in only one sex.
Niall of the Nine Hostages in Ireland (Moore, McEvoy, Cape,
Rice (1996) has documented how sexually antagonistic genes
Simms, & Bradley, 2005) and Genghis Khan in central Asia
work in fruit flies through a series of ingenious and elegant ex-
(Zerjal et al., 2003). There have been such huge disparities
periments. In one study (Rice, 1996), he prevented experimental
in patrilineage success associated with political/military dy-
group females, but not males, from evolving. After 40 genera-
nasties that there is reduced contemporary variation in the Y
tions, experimental males fathered more offspring than control
chromosome (Sykes, 2006).
males, prevented their competition from siring offspring, and
Because sexual interests have been shaped by reproductive
caused females to die younger. As expected from theory, genes
success in ancestral environments, rape is expected to be direct-
are only sexually antagonisticin theadult (reproductivelymature)
ed at reproductively relevant targets and involve reproductively
life stage (Chippendale, Gibson, & Rice, 2001). Further work has
relevant behaviors (Quinsey, 2003). Anything that causes men to
shown that female fitness losses that are occasioned by exposure
disregard the preferred mating strategies of women is expected to
to multiple males are not compensated for by the reproductive
increase the likelihood of rape. Anthropological, historical, and
performance of the females’ grandsons as would be predicted
psychological evidence suggests that warfare, alcohol intoxica-
by the ‘‘sexy sons’’ hypothesis (Orteiza, Linder, & Rice, 2005).
tion, psychopathic personality characteristics, and misogynist
This is a true arms race. It is important to be clear, however, about
attitudes contribute to rape (for an extensive review, see La-
exactly what the arms race is about:
lumière, Harris, Quinsey, & Rice, 2005). Perhaps surprisingly,
The average fitness of males and females is not inde- men who perceive themselves as highly successful with wom-
pendent because each offspring has a mother and father, en are more likely than other men to engage in date rape, pres-
and, in fact, must be equal to one another when the pri- umably because, if their current dating partner breaks off their
mary sex ratio is the typical 1:1….Therefore, one sex relationship because of sexual coercion, other partners are read-
cannot ‘‘win’’ a conflict in the sense that its fitness has ily available (Lalumière, Chalmers, Quinsey, & Seto, 1996).
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Arch Sex Behav (2010) 39:405–410 407
Although women show greater preference than men for traits in which it is clear that rape per se is not a symptom of male
in sexual partners associated with long term mating strategies, pathology because it can enhance a man’s fitness by increasing
such as resources and status, there is variance among women in his partner number or (in committed relationships) his paternal
their interest in casual relationships (e.g., Landolt et al., 1995; certainty. Sexual assault may also increase a man’s fitness be-
Provost, Kosakoski, Kormos, & Quinsey, 2006). Provost, Troje, cause it can serve to secure a long-term sexual partner. Ellis,
and Quinsey (2008) found by examining women’s preferences Widmayer, and Palmer (2009) found, in a survey of college
for variations in masculinity among point-light walkers (in- students, that women who failed to prevent a sexual assault
dividuals that are visually represented as a 15-dot point-light from eventuating in intercourse were more likely to continue to
motion display on a computer) that women using short-term date their assailant (27%) than women who blocked the assault
mating strategies prefer more masculine gait and, therefore, ge- (19%).
netic over parental contributions of mating partners more than
women using long-term mating strategies—an expected result
because short-term partners were unlikely to make parental Individual Differences
contributions in ancestral environments. Similarly, women in
the fertile phase of their cycle shifted their preference toward Marked individual differences among men in their propen-
more masculine walkers. sity to commit rape have been well documented. Some rapists
Although men interfere with women’s reproductive strategies commit large numbers of offences—once an offender has
through sexual coercion, women interfere with men’s reproduc- committed a second rape, he is highly likely to persist (La-
tive strategy of paternal investment through cuckoldry. On av- lumière et al., 2005).
erage, ancestral men who invested in children who were unre- One possibility is that this propensity simply reflects
lated to them were less reproductively successful then men who variations in antisociality (as defined by antisocial person-
invested only in their own biological children. There is evidence ality disorder or psychopathy). In fact, psychopathy is related
for genetic contributions to female infidelity (Cherkas, Oelsner, to rape to the extent that it has been argued that precocious
Mak, Valdes, & Spector, 2004) and cuckoldry is common en- and coercive sexuality is one of its defining features (Harris,
ough to lead us to expect that men may well have developed Rice, Hilton, Lalumière, & Quinsey, 2007). A recent study of
psychological adaptations to the threat of it. For example, Volk self-reported rape in a Finnish male twin sample (Johansson
and Quinsey (2002) showed that men, but not women, were et al., 2008) concluded that psychopathy, alcohol use, and
more willing to adopt babies that they believed resembled them sexual coercion were positively correlated. Heritability coef-
(a result to be expected if men have been selected to be more ficients were 60, 54, and 28% for alcohol use, psychopathy,
motivated to invest in children that appear to resemble them and and sexual coercion, respectively. A proportion of the vari-
this motivation is elicited even under conditions of adoption). In ance in sexual coercion was derived from a highly genetic
an offender sample, Camilleri and Quinsey (2009a, b) found, in source that was common with alcohol use and psychopathy.
support of the idea that men use sexual coercion to counter sperm The remainder of variance in sexual coercion was accounted
competition in committed relationships, that partner rapists often for by non-shared environmental effects.
experienced cuckoldry risk events prior to committing their of- Although highly antisocial men are much more likely to
fence and had more such experiences than non-sexual partner commit rape than less antisocial men, antisociality appears
assaulters. In a community sample, direct cues of infidelity pre- unlikely to be the only relevant individual difference. Only
dicted self-reported propensity for sexual coercion. a small proportion of men diagnosed as antisocial personal-
Women’s motivations for unfaithfulness can involve shop- ity disorder or even as psychopaths have been identified as
ping for a new partner, obtaining material advantages, and ob- rapists. Not all rapists are diagnosed with antisocial person-
taining better genes for their offspring. ‘‘Better’’ can mean several ality disorder, although the proportion is high. Fewer rapists
things in this context: For example, Garver-Apgar, Gangestad, meet the more restrictive criteria of psychopathy, although
Thornhill, Miller, and Olp (2006) found that, as major histo- the proportion of psychopaths is considerably higher among
compatibility complex similarity in romantically paired cou- rapists than among child molesters (for a review, see La-
ples increased, women’s sexual responsivity to their partners de- lumière et al., 2005).
creased and their number of extra-pair sexual partners increased. A second possibility is that the propensity to commit rape
This preference would likely result in more immunocompetent reflects sexual interest in coercive sexual acts. In this regard,
offspring. the most extensively studied characteristic of rapists is their
There are, therefore, opportunities for cooperation and con- phallometrically measured sexual interest in portrayals of sex-
flict between the sexes in reproductive behaviors. The actual ual acts varying in coerciveness. A meta-analysis of these
behaviors exhibited by individuals of either sex depend upon a studies indicated a large effect size (.82) in differentiating
variety of factors that determine their costs and benefits. Sexual identified rapists from other men (Lalumière, Quinsey, Harris,
coercion is best understood in the context of sexual conflict Rice, & Trautrimas, 2003). My colleagues and I have con-
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ducted five phallometric studies of rapists over a 22 year This interaction between psychopathy and sexual deviance
period, all of which have significantly differentiated rapists used as predictors of sexual recidivism is clear evidence that the
from non-sex offender offenders, including a group of offend- propensity to commit rape is a function of both variables.
ers that had physically assaulted women (Lalumière et al.,
2003; Quinsey & Chaplin, 1984; Quinsey, Chaplin, & Upfold,
1984; Quinsey, Chaplin, & Varney, 1981; Rice, Chaplin,
Harris, & Coutts, 1994). This is a striking illustration of robust The Question of Pathology and Diagnosis
discriminant validity.
Phallometric data show that roughly 60% of rapists show To recapitulate, sexual coercion is a manifestation of sexual
equal or greater sexual arousal to depictions of rape than con- conflict that is not in itself pathological. There are, however,
sensual sex, whereas only 10% of non-rapists do (Lalumière differences among men in their propensity to commit rape and
et al., 2003). There is some evidence that phallometric assess- this propensity is linked to antisocial personality characteristics
ment results predict subsequent sexual offending (Greenberg, and relatively more sexual interest in brutal rape depictions.
Firestone, Bradford, & Greenberg, 2002; Rice, Harris, & Quin- By Wakefield’s (1992) definition, rape-proneness meets the
sey, 1990). value criterion because rape is generally societally condemned
The phallometric data on rapists raise the question as to and can lead to incarceration or retribution from husbands or
whether rapists might be sexual sadists. It is true that rapists are relatives of the victim. It is doubtful, however, that rape repre-
best discriminated by descriptions of brutal rape depictions— sents a malfunction of the male sexual preference system be-
softer stimuli, ‘‘dates gone wrong,’’ do not differentiate rapists cause the victims are generally women of fertile age and the
from non-rapists nearly so well. Mild sadistic stimuli, such behavior increases a man’s number of sexual partners and, thus,
as descriptions of bondage and spanking with either enthusi- his fitness. This is neither to deny that rape-prone men have
astic or reluctant partners, do not differentiate rapists from dominance and aggressive aspects of the male courtship system
non-rapists (Quinsey et al., 1984). The same study, however, (Freund & Seto, 1998) tuned very high nor that they may qualify
showed that descriptions of severe non-sexual violence did for a diagnosis of antisocial personality disorder.
differentiate rapists from non-rapists with female but not (as From Wakefield’s perspective, it could be argued that rapists
expected) with male victims. Phallometric responses to non- who engage in oral or anal intercourse do suffer from a pa-
sexual violence were significantly correlated with victim in- thology because their behaviors are manifestly reproductively
jury in previous sexual offences (Quinsey & Chaplin, 1982). irrelevant. Of course, the issue does not arise if, in addition to
The small phallometric literature directly examining sadism oral and anal penetration, the offender ejaculates in the vagina.
among rapists has involved small samples and yielded incon- These observations are not meant to imply that rapists who en-
sistent results, at least partly because of varying reliability in gage in vaginal intercourse are consciously trying to have ba-
the diagnosis of sadism (for a review, see Lalumière et al., bies, any more than individuals who engage in consenting
2005). While it is clear that some rapists commit what anyone sexual behavior (usually) are.
would agree are sadistic offences, it does not appear that most At present, it is unknown what proportion of rapists engage
rapists meet the criteria for sexual sadism. exclusively in oral or anal intercourse or whether any actually
To return to the issue of whether antisociality is sufficient to prefer these activities. If we assume that such individuals exist,
account for individual differences in the propensity to commit one possible, though not satisfying, answer is that the selection
rape, there are positive, but modest, correlations between psy- for male sexual interest is not very precise, i.e., it simply directs
chopathy and phallometrically measured sexual interest in rape sexual behaviors to the right body shape but doesn’t specify the
depictions among rapists (studies reviewed in Lalumière et al., behaviors in any detail. Another, somewhat more satisfying,
2005), suggesting that antisociality is insufficient in itself. More answer is that the preference for sexual coercion includes hy-
direct evidence comes from follow-up studies of sex offender perdominant motivations, which fellatio and anal intercourse
recidivism. If antisociality and sexual interest in rape depictions express.
independently or interactively predict sexual recidivism, both There are, however, some empirical data that are relevant to
must be important. Several studies have found an interaction this kind of question. Walker (1997) examined the seriousness
between psychopathy and phallometrically measured sexual of offences among sex offenders over time from self-report and
deviance in predicting sexual recidivism among mixed samples official data (for a description of this study, see Lalumière et al.,
of sex offenders (Gretton, McBride, Hare, O’Shaughnessy, & 2005). Offenders who started with hands-off offences usually
Kumka, 2001; Rice & Harris, 1997), such that men who are did not escalate. Offenders who started with hands-on offences
both psychopathic and sexually deviant are uniquely likely to often escalated toward vaginal intercourse. Those who ‘‘over-
reoffend. Hildebrand, de Ruiter, and de Vogel (2004) found a shot’’ and injured their victims came back to intercourse. These
similar interaction between psychopathy and clinician ratings data appear to indicate that both hyperdominance and learning
of sexual deviance in a group composed exclusively of rapists. are involved.
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Arch Sex Behav (2010) 39:405–410 409
Note that this way of looking at the diagnosis of coercive role of the vasopressin receptor gene (AVPR1A). Twin Research, 7,
paraphilic disorder implies that pedophilia is a paraphilic dis- 649–658.
Chippendale, A. K., Gibson, J. R., & Rice, W. R. (2001). Negative
order (because the behavior is generally despised and is directed genetic correlation for adult fitness between sexes reveals ontoge-
toward non-reproductive individuals) but that homosexuality is netic conflict in Drosophila. Proceedings of the National Academy
not (the behavior is not generally despised nowadays in Western of Sciences of the United States of America, 98, 1671–1675.
societies, although it never leads to reproduction). As an aside, Daly, M., & Wilson, M. (1988). Homicide. New York: Aldine de Gruyter.
Ellis, L., Widmayer, A., & Palmer, C. T. (2009). Perpetrators of sexual
it is also unlikely, using Wakefield’s criteria, that antisocial assault continuing to have sex with their victims following the ini-
personality would be considered to be pathological, in part be- tial assault: Evidence for evolved reproductive strategies. Inter-
cause highly antisocial individuals tend to have children earlier national Journal of Offender Therapy and Comparative Crimi-
(for a review, see Quinsey et al., 2004). nology, 53, 454–463.
First, M. B., & Halon, R. L. (2008). Use of DSM paraphilia diagnoses in
Because I think that coercive paraphilic disorder does not sexually violent predator commitment cases. Journal of the Ameri-
fulfill the criteria for a pathology, I have not addressed the issues can Academy of Psychiatry and Law, 36, 443–454.
of diagnostic criteria nor the practical or policy difficulties that Freund, K., & Seto, M. C. (1998). Preferential rape in the theory of
the diagnosis may or may not entail (e.g., First & Halon, 2008; courtship disorder. Archives of Sexual Behavior, 27, 433–443.
Garver-Apgar, C. E., Gangestad, S. W., Thornhill, R., Miller, R. D., &
Packard & Levenson, 2006; Prentky, Coward, & Gabriel, 2008; Olp, J. J. (2006). Major histocompatibility complex alleles, sexual
Zander, 2008). It is clear, however, that there are identifiable responsivity, and unfaithfulness in romantic couples. Psycholog-
personal characteristics of rape prone men that differentiate ical Science, 17, 830–835.
them from others. Should Wakefield’s conceptualization of Greenberg, S. R., Firestone, P., Bradford, J. M., & Greenberg, D. M.
(2002). Prediction of recidivism in exhibitionists: Psychological,
pathology not be adopted in this context, a workable set of cri- phallometric, and offense factors. Sexual Abuse: A Journal of Re-
teria for diagnosis could likely be developed. These criteria search and Treatment, 14, 329–348.
would include frequency of the behavior, sexual arousal to rape Gretton, H. M., McBride, M., Hare, R. D., O’Shaughnessy, R., &
cues, and a measure of antisociality, such as the Psychopathy Kumka, G. (2001). Psychopathy and recidivism in adolescent sex
offenders. Criminal Justice and Behavior, 28, 427–449.
Checklist-Revised or quantified Antisocial Personality Disor- Harris, G. T., Rice, M. E., Hilton, N. Z., Lalumière, M. L., & Quinsey, V.
der criteria (Skilling, Harris, Rice, & Quinsey, 2002). With re- L. (2007). Coercive and precocious sexuality as a fundamental
spect to sexual arousal, phallometric assessment is the best cur- aspect of psychopathy. Journal of Personality Disorders, 21, 1–27.
rent alternative, although it is not commonly available and re- Hildebrand, M., de Ruiter, C., & de Vogel, V. (2004). Psychopathy and
sexual deviance in treated rapists: Association with sexual and non-
quires considerable standardization work. It is likely that more sexual recidivism. Sexual Abuse: A Journal of Research and Treat-
direct measures of brain activity will be developed in the future ment, 16, 1–24.
to address this issue. In short, rigorous diagnostic criteria for Johansson, A., Santitila, P., Harlaar, N., von der Pahlen, B., Witting, K.,
coercive paraphilic disorder could be developed that would Algars, M., et al. (2008). Genetic effects on male sexual coercion.
Aggressive Behavior, 34, 190–202.
permit standardization of assessment methods, calculation of Kanazawa, S. (2003). Why productivity fades with age: The crime-genius
inter-examiner agreement coefficients, and sensitivity and connection. Journal of Research in Personality, 37, 257–272.
specificity analyses. Kanazawa, S., & Still, M. C. (2000). Why men commit crimes (and why
they desist). Sociological Theory, 18, 434–447.
Acknowledgements Thanks are due to Rick Beninger, Joe Camilleri, Lalumière, M. L., Chalmers, L. J., Quinsey, V. L., & Seto, M. C. (1996).
Grant Harris, Martin Lalumière, and Marnie Rice for their comments on A test of the mate deprivation hypothesis of sexual coercion.
an earlier version of this manuscript. The author is an Advisor to the Ethology and Sociobiology, 17, 299–318.
DSM-V Paraphilias subworkgroup of the Sexual and Gender Identity Lalumière, M. L., Harris, G. T., Quinsey, V. L., & Rice, M. E. (2005).
Disorders Workgroup (Chair, Kenneth J. Zucker, Ph.D.). Reprinted with The causes of rape: Understanding individual differences in the
permission from the Diagnostic and Statistical Manual of Mental Dis- male propensity for sexual aggression. Washington, DC: Amer-
orders V Workgroup Reports (Copyright 2009), American Psychiatric ican Psychological Association.
Association. Lalumière, M. L., Quinsey, V. L., Harris, G. T., Rice, M. E., &
Trautrimas, C. (2003). Are rapists differentially aroused by
coercive sex in phallometric assessments? Annals of the New York
Academy of Sciences, 989, 211–224.
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Quinsey, V. L., & Chaplin, T. C. (1984). Stimulus control of rapists’ and Sykes, B. (2006). Saxons, Vikings, and Celts: The genetic roots of Brit-
non-sex offenders’ sexual arousal. Behavioral Assessment, 6, 169– ain and Ireland. New York: Norton.
176. Volk, A., & Quinsey, V. L. (2002). The influence of infant facial cues on
Quinsey, V. L., Chaplin, T. C., & Upfold, D. (1984). Sexual arousal to adoption preferences. Human Nature, 13, 437–456.
nonsexual violence and sadomasochistic themes among rapists and Wakefield, J. C. (1992). Disorder as harmful dysfunction: A conceptual
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Quinsey, V. L., Chaplin, T. C., & Varney, G. W. (1981). A comparison of Walker, W. D. (1997). Patterns in sexual offending. Unpublished doc-
rapists’ and non-sex offenders’ sexual preferences for mutually toral dissertation, Queen’s University, Kingston, ON, Canada.
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Arch Sex Behav (2010) 39:411–418
DOI 10.1007/s10508-009-9583-6
ORIGINAL PAPER
Evidence Regarding the Need for a Diagnostic Category

for a Coercive Paraphilia
David Thornton

Abstract Evidence relevant to a potential diagnosis of Para- What Counts as a Paraphilia?

philic Coercive Disorder is reviewed. Salient cues indicating
that their partner is feeling coerced normally at least partially Following First and Halon (2008), and in keeping with the
inhibit male sexual arousal while cues indicating mutual inter- general literature, this article takes the core of the paraphilia
est heighten arousal. However, for a minority of males, this construct to be an abnormal sexual interest. What counts as
pattern reverses with salient coercion cues leading to height- ‘‘abnormal’’is culturally relative. To be significant in a mental
ened arousal. This unusual pattern of arousal and fantasy is health context, this abnormal sexual interest needs to be suf-
associated with a self-reported willingness to rape among non- ficiently sustained and intense that it causes ‘‘clinically sig-
convicted samples and is more common among convicted rap- nificant distress or impairment in social, occupational, or other
ists than in other offender groups. It is inconsistently associated important areas of functioning.’’Included under impairment of
with Sadism as defined by the DSM-IV-TR and only weakly functioning are cases where the behavioral expression of a
associated with psychopathy or general criminality. Evidence paraphilic sexual interest causes significant harm to others.
for it as an abnormal and persistent sexual interest comes from As First and Halon (2008) note, the diagnostic language
behavioral patterns, self-reported sexual fantasy, and labora- incorporated in the DSM-IV-TR has led to some confusion
tory tests. Two possible ways of incorporating it into a future regarding the relationship between paraphilias and behavior.
version of the DSM are outlined. The DSM-IV-TR refers to‘‘recurrent, intense sexually arous-
ing fantasies, sexual urges, or behaviors.’’ Some experts have
Keywords Paraphilia Rape Sadism Paraphilic taken this to mean that a paraphilia may be constituted solely
Coercive Disorder Biastophilia DSM-V by a recurrent pattern of abnormal sexually arousing behav-
iors, something that does not seem to have been the original
intent of the DSM-IV-TR.
Introduction The position taken here is that the core of a paraphilia is an
abnormal sexual interest. The presence of a sexual interest
The purpose of this article is to articulate theoretical arguments implies that relevant fantasies and behaviors will be sexually
and review empirical evidence relevant to the need for a diag- arousing and that there will be sexual urges to engage in these
nostic category for a Coercive Paraphilia. The term‘‘Coercive fantasies and behaviors. Sexual arousal is here understood to
Paraphilia’’is used here to refer to coercive sex being the erotic be indicated by both the subjective sense of being sexually
focus of a paraphilia. aroused and bodily reactions preparatory to sexual consum-
matory behavior (such as erectile responses in men).
Inferring the presence of a sexual interest then depends on
both seeing a corresponding pattern in subjective, behavioral,
and bodily indicators of sexual interest and on evaluating and
D. Thornton (&)
being able discount alternative explanations of the observed
Sand Ridge Secure Treatment Center, P.O. Box 700,
1111 North Road, Mauston, WI 54982, USA pattern. All potentially available sources of information rele-
e-mail: [email protected] vant to this are potentially fallible so that the assessment of
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412 Arch Sex Behav (2010) 39:411–418
individuals should draw on a range of measures. Inferring the related sexual urges and fantasy. Further, it has been known
presence of offense-related sexual interests is particularly chal- for a long time that rapists in treatment not uncommonly
lenging because they may be seen as socially undesirable and, in report ongoing intense offense-related fantasy during periods
a forensic context, offenders may have good reasons to conceal of interpersonal conflict (e.g., McKibben, Proulx, & Lusignan,
them. Nevertheless, rich enough data must be gathered to infer 1994) and that among student samples self-reported willing-
the presence of a sexual interest and to discount alternatives if a ness to rape (if undetected) is substantially related to engaging
paraphilia is to be diagnosed. It is not sufficient to note a pattern in coercive sexual fantasy (e.g., Greendlinger & Byrne, 1987).
of behavior that could be explained through a paraphilia but Consistent with these reports regarding offenders’ fantasies
could equally be explained in a variety of other ways. is the literature from objective measurement of sexual response
to fantasy themes using the penile plethysmograph (PPG). This
methodology has two advantages relative to self-report: it is less
How Should a Coercive Paraphilia Be Conceptualized? dependent on the individual’s willingness to disclose the content
of their sexual fantasies and the stimuli used can be varied in a
During the 1980s, a proposed diagnostic category called Para- systematic and structured way to determine which aspect exerts
philic Coercive Disorder was formulated with the following more control over the individual’s sexual response. The method
diagnostic criteria. is, of course, fallible: men can to some extent manipulate their
penile responses and it assesses responses in the laboratory
A. Over a period of at least 6 months, preoccupation with
rather than in the real world.
recurrent and intense sexual urges and sexual arousing
There have been a series of studies examining the degree
fantasies involving the act of forcing sexual contact (for
to which relative penile response to stimuli that depict rape vs.
example, oral, vaginal, or anal penetration; grabbing a
stimuli that depict consensual sex differentiate convicted rap-
woman’s breast) on a non-consenting person.
ists. This is summarized in a so-called Rape Index, calculated
B. It is the coercive nature of the sexual act that is sexually
either as the ratio of responses to the two categories or (more
exciting, and not the signs of psychological or physical
recently) by subtracting z-scores representing the two cate-
suffering of the victim (as in sexual sadism).
gories. The expression ‘‘positive Rape Index’’ is used here to
C. The individual repeatedly acts on these urges or is mark-
refer to penile response being stronger to stimuli depicting rape
edly distressed by them.
(typically through audio or video modalities) than to stimuli
Money (1999) proposed a related but distinct conception of depicting consensual sexual activity. The term‘‘negative Rape
a paraphilic interest in rape which he called ‘‘biastophilic Index’’ is used to refer to the opposite pattern where penile
rapism.’’Here the sexual focus was on a victim who ‘‘should response is stronger to stimuli depicting consensual sexual
be maximally terror-stricken and resistant.’’ Criteria more activity than to stimuli depicting rape. The term‘‘neutral Rape
consistent with Money’s conception might instead go as Index’’will be used to describe Rape Indices that indicate about
follows. equal levels of arousal to consensual and rape stimuli. A group
A. Over a period of at least 6 months, preoccupation with may also be referred to as having a‘‘higher Rape Index’’when
recurrent and intense sexual urges and sexual arousing the average response of the group is either a more strongly
fantasies involving the act of forcing penetrative sexual positive Rape Index or a less negative Rape Index than some
contact (for example, oral, vaginal, or anal penetration) other group. Finally,‘‘deviant Rape Index’’will be used to refer
on a non-consenting person. to a Rape Index that is materially different from the Rape Index
B. It is the coercive nature of the sexual act, and the victim’s typically found for non-sexual offenders.
terror and resistance that is sexually exciting. Results from individual studies have varied; however, meta-
C. The individual repeatedly acts on these urges or is mark- analysis of these studies demonstrates a substantial difference
edly distressed by them. between convicted rapists and non-sexual offenders in average
response (Lalumière & Quinsey, 1994). Subsequent studies
There is a question of how this would be distinguished from have given variable results but the average trend is unchanged
sexual sadism but this is best addressed after seeing whether (Lalumière, Quinsey, Harris, Rice, & Trautrimas, 2003). The
either formulation is consistent with the available empirical average effect size in the studies summarized in these meta-
research. analyses was d = 0.82. This is a magnitude that is normally
considered a medium to large effect (Cohen, 1992). Lalumière
et al. (2003) stated that when using optimal test procedures
Is There Empirical Evidence for a Coercive Paraphilia? about 60% of convicted rapists show equal or greater arousal to
rape themes (as compared to consensual themes). In contrast,
There is general agreement that during treatment some rapists this pattern was shown by just 10% of non-sexual offenders
report that their offenses were preceded by intense offense- (either community members or offenders with only a record
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Arch Sex Behav (2010) 39:411–418 413
of non-sexual crimes). Since few men show exactly equal identified a subgroup of students who self-reported finding
responses to consensual and rape stimuli, this means that forcing a woman to do something she did not want to be signif-
Lalumière et al. are asserting that just under 60% of convicted icantly sexually arousing and for whom during PPG assessments
rapists have a positive Rape Index and that any positive Rape aggressive depictions (rape) elicited materially stronger penile
Index (regardless of how positive it was) should be regarded as a responses than non-aggressive consensual depictions. This
deviant Rape Index. pattern too might be regarded as indicative of a paraphilic
A limitation of this meta-analysis is that it treats all rapist interest in sexual coercion though whether a mental health
samples as if they were equivalent. It is possible that some of the diagnosis was appropriate would depend on whether it caused
variation in results between studies reflects drawing offend- clinically significant distress or impairment of functioning.
ers from samples that were higher risk/more psychologically Taking these results together, the following propositions
deviant (e.g., those evaluated at a secure forensic mental health seem to be empirically supported.
facility) as compared to routine prison samples. Willmot and Hart
1. Among non-convicted community males, sexual arousal
(1996) classified a mixed group of sexual offenders (including
is stronger to consensual than coercive themes for most
rapists and child-molesters) according to the frequency of
individuals. There is substantial variation between indi-
rapes and non-sexual assaults in their history, using an instru-
viduals in the degree to which this is true and there is a
ment developed by Thornton and Travers (1991). Scores on
minority for whom the reverse is true, i.e., sexual arousal
this instrument showed a linear relationship to a Rape Index
is stronger to coercive than to consensual themes.
(based on difference in z-scores). Consistent with other stud-
2. Among non-convicted community males, relative sex-
ies, the overall mean on the Rape Index indicated about equiv-
ual arousal to coercive vs. consensual sex is related to
alent arousal to coercive and consensual themes. Positive Rape
willingness to engage in coercive sexual behavior if the
Indices were only shown by those with more marked history
individual believes they will not be caught.
of prior rape and violence (about 40% of the sample) and was
3. A sexual preference for coercive over consensual sex is
only strong (an average difference in z-scores to coercive vs.
much more common among convicted rapists than among
consensual categories exceeding 0.5) for those with the most
non-sexual offenders, and this is particularly true if they
marked history of prior rape and violence (about 12% of the
have a history of repeated rape and non-sexual violence.
sample). Taking this result with those summarized earlier, it
4. Among convicted rapists, sexual arousal to, and fantasies
would probably be more accurate to characterize the group
about, rape are relatively stable characteristics in the sense
of men convicted and imprisoned for rape as most typically
that they are apparent in PPG assessment, and in self-
showing roughly equivalent arousal responses to rape and
report of fantasy, years after the offender last committed a
consensual themes. Included within this group, however,
rape.
would be both some individuals who showed a markedly
negative Rape Index (a pattern similar to non-sexual offend- These findings do seem to provide empirical support for
ers), a larger group with a neutral Rape Index, and others who the construct of sexual preference for coercion as a paraphilia in
showed a markedly positive Rape Index. Only this latter that the usual features of a paraphilia are present (abnormal per-
pattern might be regarded as indicative of a paraphilic interest sistent sexual interest). And the interest clearly can be intense
in sexual coercion. enough that it impairs functioning (e.g., is expressed in behavior
It is natural to wonder about the 10% of men not convicted for that causes harm to others or leads to the individual being impris-
sexual offenses whose PPG responses suggest equal or larger oned). At the same time, it is important to note that this para-
responses to rape as compared to consensual sex. Studies of non- philia seems to be present in only a minority of convicted rapists
convicted community samples generally find that, within these so that other motives clearly play an important part in many
groups, Rape Indices correlate with self-reported sexual coer- rapes.
cive behavior. Malamuth (1986) found that a Rape Index was
the strongest correlate of self-reported sexual coercion. Similar
results were found by Bernat, Calhoun, and Adams (1999) and How Should the Erotic Focus of Coercive Paraphilia
Lohr, Adams, and Davis (1997) but not by Lalumière and Be Specified?
Quinsey (1996).
In general, in these studies of non-offenders, sexual arousal Among samples of non-convicted males, sexual response to
(whether self-rated or measured through PPG) is greater to rape has been shown to depend on a number of factors, including
depictions of consensual sexual activity than to depictions of whether the victim is seen as becoming sexually aroused by (vs.
coercion. Individual differences have to do with the degree to abhorring) the rape (Malamuth & Check, 1980), on situational
which this is so with some men who show clearly negative factors like whether the individual was recently insulted by a
Rape Indices while others show more neutral Rape Indices. woman (Yates, Barbaree, & Marshall, 1984), and cultural atti-
However, Malamuth, Check, and Briere (1986) successfully tudinal factors such as beliefs supportive of rape myths, domes-
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414 Arch Sex Behav (2010) 39:411–418
tic violence, male dominance over women, adversarial relations inverse relationship (r = -0.09) among rapists. It is apparent
between men and women, and sexist attitudes about male and from this that the overlap between the Rape Index and general
female behavior (e.g., Malamuth et al., 1986). antisociality/psychopathy is too small for rapists’ deviant Rape
Lalumière and Quinsey’s (1994) meta-analysis of studies Index to be understood as primarily a result of their being gen-
comparing the phallometric rape index between convicted rap- erally antisocial. Additional doubt is cast on this idea by the
ists to non-sexual offenders found that two stimulus sets (Abel’s fact that violent non-sexual offenders do not show a deviant
set and the Quinsey et al. set) were more effective at discrimi- PPG Rape Index (Lalumière et al., 2003) even though they
nating rapists from non-sexual offenders than the set produced show equal levels of general antisociality and psychopathy.
by Barbaree’s group. Broadly, these results indicate that stim- A possibility suggested by Barbaree et al. (1979) is that non-
ulus sets which employ graphic and brutal rape stimuli are more sexual offenders inhibit their arousal to rape scenarios because
effective. Consistent with this, Lalumière et al. (2003) reported a of empathy for the woman being victimized. The deviant sex-
within-study comparison of the effect of different stimulus ual responses of rapists would then be explained as a lack of
characteristics on the degree to which they differentiated rapists. victim empathy. For this to be the case, it would need to be true
The most differentiating rape stimuli were those that presented that rapists show less empathy for women who are raped than do
rape stimuli from the victim’s point of view and depicted her as non-sexual offenders. Fernandez and Marshall (2003) inves-
experiencing intense pain and suffering. tigated this and found that convicted rapists showed empathy
Taking these results with those described in the previous towards women who had been sexually assaulted that was at
section, it would appear that the deviant sexual focus that is most least as good as that shown by non-sexual offenders. Only in
clearly associated with coercive sexual behavior is forcing sex relation to their own past victim was there a suggestion of their
upon a woman in a way that she experiences as abhorrent, humil- empathy being suppressed. Remembering that PPG rape stimuli
iating, painful or terrifying. This appears to be more consis- relate to women who have not been sexually assaulted by the
tent with Money’s (1999) ‘‘maximally terror-stricken and offender who is being assessed, these findings make it difficult to
resistant’’victim than with the conception of Paraphilic Coer- explain rapists’ deviant Rape Index on the basis of an empathy
cive Disorder proposed for the DSM in the 1980s in which the failure.
pain, fear, and suffering of the victim was meant to be sex- One positive piece of empirical support for the differential
ually irrelevant. inhibition hypothesis comes from the Dual Control model
developed by Janssen and Bancroft (2006). This model pro-
poses that sexual arousal results from the combination of two
distinct active processes, one of excitation and the other of
Is the Abnormality Solely Due to Antisociality, inhibition. Further, the model proposes that individuals differ
Callousness or a Failure of Sexual Inhibition? in the strength of each of these processes. Questionnaire
research suggests a unitary excitation factor but two inhibition
A striking feature of the comparisons between rapists and factors with sexual inhibition being triggered either by fear of
non-convicted samples is that the average profile for convicted performance failure or by fear of performance consequences.
rapists is equal sexual responsiveness to rape and consensual Janssen, Vorst, Finn, and Bancroft (2002) showed that, in a
themes while the average profile for non-sex offenders has sample of community men, those with relatively stronger fear
been clearly greater arousal to consensual than coercion themes. of performance consequences showed much stronger penile
Barbaree, Marshall, and Lanthier (1979) proposed that this response to depictions of consensual than to depictions of
was best understood as the failure of coercion, force, and so coercive sex. In contrast, those with relatively weaker fear of
on to inhibit sexual arousal rather than it representing a positive performance consequences showed penile responses to coer-
interest in these things. Their initial article speculated about cive sex that were only a little weaker than those to consensual
possible sources of this inhibition but did not provide any evi- sex.
dence to substantiate the role of any particular source. This is a single study of a community sample of presumably
Consistent with this proposal, Lalumière et al. (2003) have non-convicted men. The results need replicating in further com-
observed that rapists typically have a generally antisocial life- munity samples and extending to samples of convicted rap-
style that involves a relative insensitivity to the feelings and ists. Nevertheless, they do provide some evidence for the role
interests of others, and, as part of this, show higher levels psy- of an inhibitory process in explaining some of the variation
chopathic traits. They reported a correlation between the Rape between individuals in their sexual response to coercive themes.
Index and the PCL-R of 0.23. Serrin, Malcolm, Khanna, and Of course, inhibition models of whatever kind are not able
Barbaree (1994) also a reported this correlation to be in the .20s to explain the sexual arousal patterns of men who respond
but Firestone, Bradford, Greenberg, and Serran (2000) found a more strongly to depictions of coercive sex than to depictions
correlation of only 0.11 in their overall sample which included of consensual sex. Thus, at most, this kind of explanation can
child-molesters and incest offenders as well as rapists and an only be part of the story.
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Arch Sex Behav (2010) 39:411–418 415
Is This Simply Sexual Sadism? (injury), non-consenting non-sexual violence (coercion and
injury), and sadistic rape (coercion, injury and sex). In con-
An obvious issue is whether this sexual arousal to forcing sex trast, they actually showed weaker arousal to non-sadistic
upon a woman in a way that she experiences as abhorrent, rape stimuli (coercion and sex).
humiliating, painful or terrifying is simply an expression of Harris et al. (2009) used the same stimulus set to compare
more general sexual sadism. convicted rapists to controls. The rapists showed markedly
There are some arguments in favor of seeing it as sexual stronger arousal than controls to stimuli depicting non-sadistic
sadism. To begin with, being sexually excited by this kind of rape and markedly weaker arousal than controls to stimuli
rape seems to be an example of being excited by ‘‘psycho- depicting consensual non-sadistic sexual activity. In contrast,
logical or physical suffering (including humiliation) of the rapists showed only weak differences from controls on stimuli
victim.’’It seems likely that preferential sexual arousal to this depicting either consensual sadistic sex or sadistic rape.
kind of coercion is for some men an expression of a more gen- Taken together, these results are not consistent with the idea
eral sadistic sexual focus (in which their arousal is also trig- that preferential sexual arousal to rape is simply an expression
gered by torture, killing, physical destruction of the victim, of more general sexual sadism. Rather, there seems to be more
etc.). However, it may be that in other men the paraphilic focus than one paraphilic focus that is relevant here. There is a non-
is narrower so that they are aroused by this kind of coercive sadistic form of paraphilia relevant to rape where the para-
rape but not by other kinds of sadistic activities. The issue then philic focus is coercing another into sexual activity with key
is how frequently this second kind of sexual interest pattern is cues necessary to elicit the arousal being those that maximize
encountered. If the great majority of those with a positive Rape how salient coercion is. In contrast, there is a sadistic para-
Index are sexual sadists, then there should be a strong and con- philia which can be expressed in some kinds of rape but is
sistent relationship between clinically identified sexual sadism also expressed in non-sexual sadistic activities (consensual
and the Rape Index. On the other hand, if sexual sadists are and non-consensual) and in consensual sadistic sexual activi-
only a minority of those with a positive Rape Index, then a ties where the central cue eliciting arousal is causing injury to
weak or inconsistent relationship would be expected. the other person.
Some studies have indeed found a more deviant PPG rape
index for convicted rapists classified as sadistic as compared
Case Illustrations
to other rapists (Barbaree, Seto, Serin, Amos, & Preston, 1994;
Preston, 1996; Proulx, 2001) though the difference has not
Two case examples are presented to illustrate the kind of pre-
always been statistically reliable. However, other studies have
sentation to which a diagnosis like Paraphilic Coercive Disorder
given different results. Langevin et al. (1985) found that sadistic
might be applied. The two cases were selected with the assis-
rapists had a lower rape index than non-sadistic rapists. This
tance of Dr. Susan Sachsenmaier, a clinical psychologist with
difference was not statistically reliable. However, similar results
extensive experience in forensic evaluation who currently leads
(indicating relatively lower Rape Indices among sadistic rap-
a team of forensic evaluators employed by the Department of
ists) were also obtained by Seto and Kuban (1995) and by
Health Services in the State of Wisconsin. Dr. Sachsenmaier
Marshall, Kennedy, and Yates (2002). Taken together, there is
judged these cases as meeting the criteria for Paraphilic Coer-
no overall relation in these studies between sexual sadism and
cive Disorder proposed under Option 2. In addition to high-
the PPG Rape Index: in half the studies, a positive relationship
lighting the kind of forensic data relevant to diagnosis in a
between sexual sadism and the Rape Index is suggested and in
forensic context, additional clinical data are presented of a kind
half the studies a negative relationship is suggested.
that might inform diagnosis in a clinical/therapeutic context. To
Research with a more recently constructed PPG stimulus
preserve patient confidentiality, incidental features of the cases
set has helped to clarify the situation. This stimulus set was
have been altered or features from similar cases merged into a
designed to disentangle the effects of three different stimulus
single composite individual portrait. Features relevant to diag-
dimensions: coercion, injury, and sexual activity.
nosis have been accurately summarized.
Seto, Lalumière, Harris, and Chivers (2009) used the new
stimulus set to compare sadists and normal controls. During
PPG assessment, men identified as sadists based on their self- Case 1
reported sexual interests differed from normal controls primarily
in how their penile response was affected by the injury dimension. Mat’s official record shows that while in his 20s over a period
The two groups showed little difference in how their penile of 5 years he attempted to rape one woman and succeeded in
response was affected by the coercion dimension. Thus, for raping two others. In each case, he used a knife to gain and
example, the sadists showed stronger sexual responses than maintain control of obviously unwilling victims. The victims
controls to stimuli depicting consenting sadistic activity were strangers to him. In two cases, he had broken into the
(combining injury and sex), consenting non-sexual violence victim’s homes. Threats to the victims’ children and in one
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416 Arch Sex Behav (2010) 39:411–418
case hitting the victim with a club were also used to coerce the In addition to his official record, Luke has reported that,
victim. The record also showed an earlier series of less intrusive beginning in his teenage years, he would grab girls about his own
sexual assaults in which knives were also used to coerce the age, hold them down, and touch their vaginal areas. During high
victim. As a child, he had briefly exposed himself and engaged school, he was reprimanded for grabbing girls and pulling them
in sexual activities with animals. His school record showed a into a school restroom to sexually touch their breasts and vaginas.
pattern of sexually grabbing female classmates that persisted He also repeatedly made obscene telephone calls to girls from
despite complaints about this harassment and interventions school and continued this behavior after leaving school.
from school staff. In addition to his official record, Mat has Luke has apparently had sexual relationships of a somewhat
reported carrying out a further four undetected rapes and having consenting kind with three women, in two cases living with the
a pattern of searching public areas looking for vulnerable woman. In one case, there is no information about the quality
women to sexually assault and breaking into homes in the hope of the relationship, in one he was clearly abusive (name calling,
of finding vulnerable women alone. violently holding down and slapping his partner), and in one he
Mat has been noted to spend hours masturbating many days. repeatedly engaged in sexual activities which have some rela-
He has sometimes reported violent sexual fantasy to clinical tionship to his offenses, including tying his partner up during
staff and sometimes has claimed only to have consensual fan- sex and treating her roughly. It is reported that he ejaculated
tasies. In one interview, he stated that he required violent sex- numerous times during these‘‘rough’’ sexual activities.
ual fantasies to reach orgasm. In filling in a questionnaire, he Luke’s own account of his experience of consenting sexual
reported fantasizing about raping a female member of staff. activity depicts it as leaving him feeling inadequate and pow-
Later, he claimed that his masturbatory fantasies were entirely erless. In contrast, from his later teenage years onwards, he
to consensual imagery; however, when given a polygraph reported regularly fantasizing about raping women even at
examination in relation to this he tested as‘‘deceptive.’’ times when he had access to sexual intercourse with a girlfriend.
Mat has participated in a penile plethysmograph (PPG) In these fantasies, he felt sexually powerful, dominant, and in
assessment. He showed clinically significant levels of penile control. Luke described his rapes as preceded by repeated rape
response to the stimulus segment depicting the rape of an adult fantasies and as being carefully planned so as to avoid detection.
female while showing non-significant levels of response to the He described spending large amounts of free time researching
segment depicting consensual sex with an adult female. His which women were in a vulnerable position, where they lived,
response to the rape stimulus was more than twice the mag- their daily routines, and when he could most easily rape them.
nitude of his response to the consensual stimulus. He would then use his notes on his researches in conjunction
Apart from his sexual offending, Mat has no record of with pornography when masturbating. He further reported that
serious criminal behavior and scores as low on psychopathic he continued to masturbate to rape fantasies over a period of
traits according to the PCL-R. He is also of below average over 15 years while in prison.
intelligence. Luke has no record of serious criminal activity other than
his sexual offenses. He scores as low on psychopathic traits
according to the PCL-R and is of average intelligence.
Case 2
Luke’s official record shows that while in his 20s over a period Summary
of about 2 years he carried out intrusive sexual assaults on nine
females. The victims covered a wide age range from older teen- There is significant empirical support for the existence of a
agers to a older adults though most were in their 20s. Some of the distinctive coercive paraphilia among men convicted of rape.
victims were acquaintances but most were strangers. Substantial This paraphilia involves preferential sexual arousal to forcing
coercion was apparent in each offense, including violently sex upon a woman in a way that she obviously experiences as
tearing the victim’s clothes off and repeatedly striking them to coercive. Development of the paraphilia may depend, in part,
induce compliance or threatening them with a knife. Once a on a failure of inhibitory processes but it also involves this
victim was cowed into submission, Luke would impose sexual erotic focus being a positive excitatory source of sexual arousal.
activities, including digitally penetrating her vagina, requiring Although conceptually related to sexual sadism, it represents a
her to stimulate his penis with her hands or mouth, and/or distinct paraphilia.
penetrating her vagina with his penis. Once a victim stopped
resisting, he did not continue hitting her. In some offenses, he
wore a mask; in one, he bound the victim’s hands and feet before Recommendations for Diagnostic Criteria
he left her. It is notable that during the time he committed these
sexual assaults Luke had a girlfriend who was willing to have Two options consistent with the existing data are articulated
sexual intercourse with him. below:
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Arch Sex Behav (2010) 39:411–418 417
Option 1 Barbaree, H. E., Seto, M. C., Serin, R. C., Amos, N. L., & Preston, D. L.
(1994). Comparisons between sexual and nonsexual rapist subtypes:
Sexual arousal to rape, offence precursors, and offense character-
Define what has been referred to here as coercive paraphilia as istics. Criminal Justice and Behavior, 21, 95–114.
a form of sexual sadism. It would require interpreting another’s Bernat, J. A., Calhoun, K. S., & Adams, H. E. (1999). Sexually aggressive
experience of coercion as a form of psychological suffering. and nonaggressive men: Sexual arousal and judgments in response
This has the advantage of conceptual simplicity and would be to acquaintance rape and consensual analogues. Journal of Abnor-
mal Psychology, 108, 662–673.
consistent with the notion that sexual sadists typically develop Cohen, J. (1992). A power primer. Psychological Bulletin, 112, 155–159.
distinct, even idiosyncratic, foci to their paraphilia. The diag- Fernandez, Y. M., & Marshall, W. L. (2003). Victim empathy, social
nosis might then be accompanied by a specifier that defined the self-esteem, and psychopathy in rapists. Sexual Abuse: A Journal
idiosyncratic focus. Thus, one might have diagnoses such as of Research and Treatment, 15, 11–26.
Firestone, P., Bradford, J. M., Greenberg, D. M., & Serran, G. A. (2000).
‘‘sexual sadism–coercion’’ or ‘‘sexual sadism–torture/homi- The relationship of deviant sexual arousal and psychopathy in incest
cide’’ or ‘‘sexual sadism–humiliation,’’ etc. The disadvantage offenders, extrafamilial child molesters, and rapists. Bulletin of the
of this formulation is that it would be likely to lead to a far American Academy of Psychiatry and Law, 28, 303–308.
larger number of offenders being identified as sexual sadists. First, M. B., & Halon, R. L. (2008). Use of DSM paraphilia diagnoses in
sexually violent predator commitment cases. Bulletin of the American
Sexual sadism is a diagnosis that carries an enormous weight in Academy of Psychiatry and Law, 36, 443–454.
forensic contexts. Perhaps it is better reserved for a narrower Greendlinger, V., & Byrne, D. (1987). Sexual fantasies of college men as
group of offenders. predictors of self-reported likelihood to rape and overt sexual aggres-
sion. Journal of Sex Research, 23, 1–11.
Harris, G., Chaplin, T., Cormier, C., Lalumière, M., Lang, C., Rice, M.,
Option 2 et al. (2009, October). Rapists’ sexual responses to phallometric
stimuli emphasizing serious injury to victims: testing sexual interest
Provide a distinct diagnosis of Coercive Paraphilia with rules in coercion as a paraphilia. Paper presented at the Annual Research
to indicate when it or sexual sadism should be used. Possible and Treatment Conference, Dallas, TX.
Janssen, E., & Bancroft, J. (2006). The dual control model: The role of
diagnostic criteria for Coercive Paraphilia might be as follows: sexual inhibition and excitation in sexual arousal and behavior. In
E. Janssen (Ed.), The psychophysiology of sex (pp. 197–257).
Paraphilic Coercive Disorder Bloomington, IN: Indiana University Press.
Janssen, E., Vorst, H., Finn, P., & Bancroft, J. (2002). The Sexual
A. Over a period of at least 6 months, recurrent, intense sex- Inhibition (SIS) and Sexual Excitation (SES) Scales: II. Predicting
ually arousing fantasies or sexual urges focused on sexual psychophysiological responses patterns. Journal of Sex Research,
39, 127–132.
coercion, as indicated by self-report, laboratory testing, or
Lalumière, M. L., & Quinsey, V. L. (1994). The discriminability of
behavior. rapists from non-sex offenders using phallometric measures: A
B. The person is distressed or impaired by these attractions, meta-analysis. Criminal Justice and Behavior, 21, 150–175.
or has sought sexual stimulation from forcing sex on three Lalumière, M. L., & Quinsey, V. L. (1996). Sexual deviance, antisoci-
ality, mating effort, and the use of sexually coercive behaviors.
or more non-consenting persons on separate occasions.
Personality and Individual Differences, 21, 33–48.
C. The diagnosis of Paraphilic Coercive Disorder is not Lalumière, M. L., Quinsey, V. L., Harris, G. T., Rice, M. E., & Trautrimas,
made if the patient meets criteria for a diagnosis of Sexual C. (2003). Are rapists differentially aroused by coercive sex in
Sadism Disorder. phallometric assessments? In R. A. Prentky, E. Janus, & M. Seto
(Eds.), Sexual coercion: Understanding and management (pp. 211–
Note that the above uses the general formulation employed in 224). New York: New York Academy of Sciences.
DSM-IV-TR except that the troublesome ‘‘or behavior’’ lan- Langevin, R., Ben-Aron, M. H., Coulthard, R., Heasman, G., Purins, J.
E., & Handy, S. J. (1985). Sexual aggression: Constructing a
guage has been dropped. prediction equation. A controlled pilot study. In R. Langevin (Ed.),
Erotic preference, gender identity, and aggression in men: New
Acknowledgements The author is an Advisor to the DSM-V Paraph- research studies (pp. 41–76). Hillsdale, NJ: Erlbaum.
ilias subworkgroup of the Sexual and Gender Identity Disorders Work- Lohr, B. A., Adams, H. E., & Davis, J. M. (1997). Sexual arousal to erotic
group (Chair, Kenneth J. Zucker, Ph.D.). I wish to thank members of the and aggressive stimuli in sexually coercive and noncoercive men.
subworkgroup for their discussion of an earlier version of this paper and Journal of Abnormal Psychology, 106, 230–242.
their role in refining and developing the diagnostic options that are dis- Malamuth, N. M. (1986). Predictors of naturalistic sexual aggression.
cussed. Reprinted with permission from the Diagnostic and Statistical Journal of Personality and Social Psychology, 50, 953–962.
Manual of Mental Disorders V Workgroup Reports (Copyright 2009), Malamuth, N. M., & Check, J. V. P. (1980). Penile tumescence and
American Psychiatric Association. perceptual responses to rape as a function of victim’s perceived
reactions. Journal of Applied Social Psychology, 10, 528–547.
Malamuth, N. M., Check, J. V. P., & Briere, J. (1986). Sexual arousal in
response to aggression: Ideological, aggressive, and sexual corre-
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Marshall, W. L., Kennedy, P., & Yates, P. (2002). Issues concerning the
Barbaree, H. E., Marshall, W. L., & Lanthier, R. D. (1979). Deviant reliability, and validity of the diagnosis of sexual sadism applied in
sexual arousal in rapists. Behaviour Research and Therapy, 17, prison settings. Sexual Abuse: A Journal of Research and Treatment,
215–222. 14, 301–311.
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McKibben, A., Proulx, J., & Lusignan, R. (1994). Relationships between Seto, M. C., & Kuban, M. (1995). Criterion-related validity of a
conflict, affect and deviant sexual behaviors in rapists and pedo- phallometric test for paraphilic rape and sadism. Behaviour Research
philes: The assessment and treatment of sex offenders. Behaviour and Therapy, 34, 175–183.
Research and Therapy, 32, 571–575. Seto, M. C., Lalumière, M., Harris, G. T., & Chivers, M. L. (2009,
Money, J. (1999). The lovemap guidebook: A definitive statement. New October). Distinguishing biastophilia and sadism: The relative
York: Continuum. importance of violence and non-consent cues. Paper presented at
Preston, D. L. (1996). Patterns of sexual arousal among rapist subtypes. the Annual Research and Treatment Conference, Dallas, TX.
Dissertation Abstracts International: Section B: The Sciences & Thornton, D., & Travers, R. (1991). A longitudinal study of the criminal
Engineering, 56(11-B), 6445. behaviour of convicted sex offenders. In Proceedings of the Prison
Proulx, J. (2001, November). Sexual preferences and personality Psychologists’ Conference. London: Her Majesty’s Prison Service.
disorders of MTC:R3 rapist subtypes. Symposium presented at the Willmot, P., & Hart, C. (1996). Sexual preferences of violent sexual
meeting of the Association for the Treatment of Sexual Abusers, offenders. In Programme Development Section, Her Majesty’s Prison
San Antonio, TX. Service. The treatment of imprisoned sex offenders. London: Home
Serrin, R. C., Malcolm, P. B., Khanna, A., & Barbaree, H. E. (1994). Office Publications Unit.
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DOI 10.1007/s10508-009-9571-x
ORIGINAL PAPER
Is a Diagnostic Category for Paraphilic Coercive Disorder

Defensible?
Raymond A. Knight

Abstract There is a proposal to establish a paraphilic co- Introduction

ercive disorder as a new paraphilia in the DSM-V. The empir-
ical data do not, however, support the hypothesis that a dis- The DSM-III-R (American Psychiatric Association, 1987)
tinct syndrome exists that comprises males who are sexually Paraphilia Subcommittee proposed that a coercive paraphilia
aroused by the coercive elements of rape per se. Purported category should be added to the paraphilias. Several factors
evidence for this syndrome has centered on the results of were cited in support of their proposal. First, the extant
phallometric studies. Higher plethysmographic responses of phallometric data on sexually aggressive males suggested
rapists to coercive rape scenarios may, however, be better that there was a subset of rapists who, relative to controls,
explained by the failure of coercive elements to inhibit a- showed high rape indices (the ratio of plethysmographic
rousal to sexual aspects of the stimuli rather than by arous- [PPG] responses to stimuli associated with sexual coercion
al specifically to the coercive elements. In addition, sexual relative to their responses to stimuli depicting mutually
fantasies about forcing sex and about struggling victims are consenting sexual activity (e.g., Abel, Barlow, Blanchard, &
highly correlated with sadistic fantasies and have not been Guild, 1977; Barbaree, Marshall, & Lanthier, 1979; Earls &
shown to identify a syndrome that can be discriminated from Proulx, 1986; Quinsey & Chaplin, 1984; Quinsey, Chaplin,
sadism. Finally, taxometric evidence strongly supports the & Varney, 1981). Second, in a number of the typological
hypothesis that the underlying components of rape are dis- systems for rapists that had been proposed up to that time, a
tributed as dimensions and do not constitute a separate taxon. specific type of rapist had been identified whose motivation
Consequently, the criteria purported to categorize rapists into was hypothesized to be predominantly sexual (for a review,
the proposed syndrome would have to be arbitrarily deter- see Knight, Rosenberg, & Schneider, 1985). Third, Freund
mined. Not only does there seem to be little empirical justi- had proposed in his courtship disorder theory that some forms
fication for the creation of this new syndrome, the inclusion of of rape involved distortions of normal courtship behavior
this disorder among the paraphilias would have serious po- (Freund, Scher, & Hucker, 1983, 1984; Freund, Scher, Ra-
tential for misuse. It would imply endorsement of Paraphilia, cansky, Campbell, & Heasman, 1986). Here, aberrant sexual
NOS, nonconsent, which is currently inappropriately employed arousal was hypothesized to be a key motivational compo-
in civil commitment proceedings to justify commitment. nent at least for a significant subset of rapists, called prefer-
ential types (Freund, Seeley, Marshall, & Glinfort, 1972).
Keywords Paraphilias Paraphilic coercive disorder The preferential rapist was hypothesized to be a paraphiliac,
Sadism DSM-V like the voyeur, the exhibitionist, and the frotteurist; and all
of these paraphiliacs were hypothesized to represent distor-
tions of normal courtship. This theory was consistent with the
high instance of paraphilias found among sex offenders (e.g.,
Abel, Becker, Cunningham-Rathner, Mittelman, & Rouleau,
R. A. Knight (&)
1988; Abel & Blanchard, 1974; Freund, 1990).
Department of Psychology, MS 062, Brandeis University,
Waltham, MA 02454-9110, USA The introduction to the DSM-III-R of a specific diagnostic
e-mail: [email protected] category for either biastophilia (a supposed paraphilia in
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420 Arch Sex Behav (2010) 39:419–426
which non-consent, struggling, or resisting were hypothe- the physical or emotional suffering that he inflicts on another
sized to be sexually arousing) or a more generic paraphilic or from his control of, or domination over, others. The core
coercive disorder (PCD) for preferential rapists was rejected feature in the various proposed definitions of sadism has
more for political reasons than for any extant disconfirming been a fusion of sexual arousal, sexual fantasy, and a variety
empirical evidence about the validity of identifying such an of aggressive and cruel behaviors (Knight & Prentky, 1990;
hypothesized subset of rapists (Fuller, Fuller, & Blashfield, Marshall & Kennedy, 2003). Archival records often lack
1990). Although more recent data have continued to support information about the offender’s cognitions, fantasies, and
the importance of the roles of both sexual motivation and feelings. Yet, such records have been the source for making
sexual deviance in coercive sexual behavior (e.g., Knight, the diagnosis of sadism in most of the extant research. Con-
Ronis, Prentky, & Kafka, 2009; Knight & Sims-Knight, 2003, sequently, clinicians have drawn inferences about the moti-
2004), the original reasons for proposing a diagnostic category vation, arousal, and pleasure of the offender in the offense
for paraphilic preferential rapists have encountered some chal- without the appropriate supporting evidence (Knight, Prent-
lenging disconfirmations that question whether sexual arousal ky, & Cerce, 1994). Inferring sexual arousal to injury or dis-
to coercive stimuli adequately accounts for the phallometric data, tress even from detailed descriptions of offense behavior is a
whether sexual arousal to coercion per se can be discriminated formidable task (Prentky & Knight, 1991).
from sadism, and whether a distinct taxon of paraphilic rapists It is not surprising, therefore, that the data on the relation of
can be identified. I will address each of these issues in turn. sadism to the rape index have been mixed. Studies that have
used DSM criteria (Marshall & Kennedy, 2003; Seto & Ku-
ban, 1996) have failed to find a positive relation between
sadism so defined and the rape index. Indeed, Marshall and
What is PPG Measuring in Rapists?
Kennedy (2003) found a significant negative relation be-
tween the diagnosis and the rape index, but they also found
Although PPG data on sexual coercion have continued to
that their nonsadists were significantly higher than sadists on
support the hypothesis that rapists respond with higher sexual
beating and torturing their victims, seriously questioning the
arousal to coercive sex stimuli than non-sex offenders (e.g.,
validity of the DSM clinical diagnoses. In Seto and Kuban’s
Lalumière, Quinsey, Harris, Rice, & Trautrimas, 2003), the
(1996) study, although the DSM-diagnosed sadistic rapists
hypothesis that rapists are sexually aroused by the coercive
who did not admit sadistic fantasies did not differ signifi-
aspects of the stimuli used in PPG assessment has not been
cantly from any other offender group or community controls,
convincing. Two bodies of research challenge the hypothesis
a group that included self-identified sadistic fantasizers, who
that a subset of rapists is sexually aroused by coercion per se.
had not acted on these fantasies, was the only group that
The first is the research on sadism, which suggests that there is
differed significantly from community controls on arousal to
little or no support in the PPG data for a category of PCD
violent rape and to nonsexual violence (see Table 2 in Seto
independent of sadism. The second body of research supports
& Kuban, 1996). Langevin et al. (1985), who confounded
an inhibitory hypothesis that provides an alternative and
sadism with PCD because they included in their sadism group
arguably more consistent explanation of the rape index re-
those with ‘‘inordinate arousal to control of victims’’ (p. 48),
sults than the preferential sexual arousal to coercion expla-
found no relation between sadism and the rape index.
nation. I will discuss each in turn.
The definition of sadism in the Massachusetts Treatment
Center: Rapist Typology, Version 3 (MTC:R3; Knight, 1999,
Research on Phallometry and Sadism 2009; Knight & Prentky, 1990) provides specific behavioral
criteria for sadism in an attempt to enhance diagnostic reli-
The vast array of criteria generated to define sadism has ability and attains at least minimally acceptable reliability in
provided little basis for cross-study comparisons and gener- this judgment. Phallometric assessments of MTC:R3 subtypes
alization (Marshall & Kennedy, 2003). A wide variety of of rapists have found high rape indices in Overt Sadists more
violent behaviors has been proposed to identify the sadistic consistently than the previously described studies. Relative to
offender, including, for example, a pattern of extreme, gra- other rapist types, Overt Sadists have produced the highest rape
tuitous violence in the offense that often focuses on eroge- indices of all rapist types (Barbaree, Seto, Serin, Amos, &
nous areas of the body and is sometimes characterized as Preston, 1994; Preston, 1996; Proulx, 2001). In the two studies
bizarre or ritualized, humiliation or degradation of the victim, that used more discriminating and more violent audio stimuli
torture or mutilation of the victim, and acts in the offense (see Quinsey, Chaplin, & Upfold, 1984), the MTC:R3 Vin-
manifesting domination and control over the victim (Knight dictive type of offender was also found to produce rape indices
& Prentky, 1990; Marshall & Hucker, 2006; Prentky & more like the Overt Sadists, whereas the less violent Non-
Knight, 1991). It is, however, considered central to the defi- Sadistic Sexual type, whose categorization criteria included
nition of sadism that the sadist derives pleasure either from the presence of hypersexuality, sexual deviance, or paraphilias,
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Arch Sex Behav (2010) 39:419–426 421
showed rape indices that were indistinguishable from non- more aggressive rapists have also tended to score higher on
sexual Opportunistic offenders (Preston, 1996; Proulx, 2001). the PCL-R (Knight, 2009; Sitnikov, Goldberg, Daversa, &
These results were consistent with the general finding that the Knight, 2007). There is little evidence that high sexualiza-
largest effect size estimates in studies discriminating rapists tion, the presence of paraphilias, or sexual deviance per se
from controls on the rape index have used more violent and contributes substantially to the rape index. In all three
graphic stimuli (Lalumière & Quinsey, 1994; Lalumière et al., MTC:R3 PPG studies, the Non-sadistic Sexual types both did
2003). Subsequent research on Vindictive offenders has found not differ in their rape indices from non-violent, nonsexual
that they could not be distinguished from the Overt Sadists in types (i.e., the Opportunistic types) and were lower than the
their self-reported level of sadism on the Multidimensional Overt Sadists. There are some data (Janssen, Vorst, Finn, &
Assessment of Sex and Aggression (MASA) (Knight, 1999, Bancroft, 2002) that suggest that there are individual differ-
2009), and they were higher on sadism scales than non-violent ences both in sexual excitation and inhibition, and some
MTC:R3 offender types. Although other studies (Harris, 1998; evidence supports the hypothesis that paraphilias covary with
Lalumière et al., 2003) have also found that rape indices cor- hypersexuality (Kafka & Hennen, 2003). These data would
related moderately with scores on the Psychopathy Checklist- suggest that individual differences in inhibition and not in
Revised (PCL-R; Hare, 2003), the stronger covariates appear excitation more likely explain the differential PPG responses
to be sadism and violence. in the MTC:R3 subtypes, because the presence of sexual vio-
lence proclivities and not the presence of paraphilias in
offenders has been related to the rape index. These data do not
Experimental Manipulation of Stimuli in Phallometry provide any support for the hypothesis that there exists a sub-
set of sex offenders who are differentially sexually aroused
Barbaree and Marshall (1991) proposed an inhibition model either provide data to counter the inhibition explanation or
of sexual coercion to explain sexually coercive males’ higher look elsewhere for support for this hypothesized diagnostic
arousal to coercive sexual stimuli. Their theory provides a entity.
potential explanation for the PPG results. Descriptions of
foreplay and of the women’s physical characteristics in
consensual sex scripts have been found to increase sexual
arousal for most men. The introduction of force and the Role of Sadism and Sexualization in Rape
consequent descriptions of pain, distress, and fear on the part
of the woman in coercive scripts are hypothesized to inhibit Role of Sadism in Fantasies About Sexual Offenses
sexual arousal for non-coercive males, but not for coercive
males. This explanation is consistent both with the finding In the factor analytic studies of offense planning items in the
that rapists are not sexually aroused by scripts depicting non- MASA and its revised clinical version, the Multidimensional
sexual violence (e.g., Lalumière et al., 2003) and with PPG Inventory of Development, Sex, and Aggression (MIDSA)
studies that have examined the issue experimentally in non- (MIDSA, 2008), four robust factors have emerged that have
criminal samples (Bernat, Calhoun, & Adams, 1999; Lohr, been consistent across adult and juvenile offender samples,
Adams, & Davis, 1997). In both the Lohr et al. and the Bernat indicating that fantasies and cognitions about future offenses
et al. experimental studies of college males, coercive ele- do not constitute a univocal construct. The first factor com-
ments were added to scenarios in sequential time blocks. bines the respondent’s fantasies about what sexual acts he
Across multiple stimulus manipulations, the self-identified would perform or would have the victim do to or for him
sexually coercive males consistently produced patterns of sexually with fantasies that Cohen, Garofalo, Boucher, and
responding that indicated that their sexual arousal was not Seghorn (1971) attributed to their compensatory rapist type
inhibited by the introduction of coercive elements, whereas and Groth, Burgess, and Holmstrom (1977) saw as charac-
non-sexually coercive males showed initial sexual arousal teristic of their similarly defined power-reassurance rapist.
that was inhibited when coercive elements were introduced. Hazelwood (1987) has referred to these as pseudo-unselfish
The arousal trajectories of the self-identified sexually coer- fantasies, and Marshall (1989) discussed them in the context
cive males did not show increased arousal to coercive ele- of seeking intimacy; hence, its name—Intimacy-Seeking
ments compared to their responses to consensual sexual Sexual Fantasies. In these fantasies, the rapist ignores the
stimuli. agonistic nature of the sexual assault and fantasizes that his
The most parsimonious explanation of all of these data sexual overtures will elicit a positive response in the victim.
would hypothesize that more expressively aggressive rapist The second factor, Aggressive/Violent Fantasies, taps the
types have produced higher rape indices because their arousal offender’s fantasies about physically harming, frightening,
to the sexual components of rape scenarios is less inhibited and even killing the victim. The third factor, Explicit Plan-
by violence and coercion than non-violent offenders. These ning, captures both the offender’s forethought in seeking a
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particular victim and his fantasies about a particular location MIDSA (MIDSA, 2008) than non-coercive males. Residen-
for an assault. The fourth, Eluding Apprehension, taps his tial juvenile sex offenders have also been found to score higher
plans to evade apprehension after the crime. on these scales than non-sexual delinquents (Zakireh, Ronis,
In the MASA and the MIDSA, one item asks about the & Knight, 2008). Moreover, sexual drive, preoccupation, and
frequency of having thoughts about forcing someone to have compulsivity have also been found to correlate highly with
sex. There are also four items that capture the core of a pur- each other and, in turn, with pornography use, expressive ag-
ported PCD (reporting masturbating to the thought of forcing gression toward women, sadism, pervasive anger, and offense
someone to have sex and being sexually aroused by making a planning for adult and juvenile sex offenders (Knight, 1999;
woman do what the respondent wants sexually, by having a Knight & Cerce, 1999).
woman struggle, and by thoughts of overpowering someone). In etiological models of sexual aggression directed both at
For 529 adult sex offenders, the Cronbach alpha of this four- women (Knight & Sims-Knight, 2003, 2004) and at children
item PCD scale was .83. For the subset of this sample who exclu- (Daversa & Knight, 2007), such appetitive fantasies and behav-
sively assaulted women ([16 years old), the correlation between iors have played a mediating role, predicting the frequency of
PCD scale and the thinking about forcing sex item was r(186) = coercive behavior both against peers and adult women and
.75, p \ .001, but the PCD scale correlation with the sexual against children for both juveniles and adults. In the Knight and
sadism fantasy scale was even higher, r(186) = .76, p \ .001. Sims-Knight (2003, 2004) model for rape, the relation between
When we partialled out sadism and the Intimacy-Seeking Fan- sexualization and sexual coercion was mediated by expressive
tasies factor, the correlation between the PCD scale and the aggressive and sadistic fantasies. Lussier, Leclerc, Cale, and
frequency of thinking about rape dropped to r(176) = .40, Proulx (2007) corroborated the importance of sexualization in
p \ .001. Thus, it appears that the majority of the PCD scale developmental path models for both rapists and child molesters.
variance is associated with sadism. Moreover, although signif- In the former group, sexualization and externalization yielded
icant, only a small portion of its variance ([.40]2 = 16%)was the best fitting model, and in the latter the addition of an inter-
uniquely related to fantasies about sexually coercing someone. nalization latent trait improved the model. In a nationally rep-
Clearly, generic fantasizing about rape cannot be used as a cri- resentative sample of adolescent males, Casey, Beadnell, and
terion for PCD without first excluding the sadism and pseudo- Lindhorst (2009) also corroborated the importance of compo-
intimacy components from such fantasy reports. Given the nents of sexuality and delinquency for predicting sexually coer-
difficulty measuring sadism (Marshall & Hucker, 2006; Mar- cive behavior in adulthood.
shall & Kennedy, 2003), this is a daunting task that does not The high prevalence of paraphilias that has been found
bode well for reasonable levels of reliability. among sex offenders (Abel & Osborn, 1992; Abel & Rouleau,
1990; Abel et al., 1988; Freund, 1988, 1990) is also consistent
Role of Sexualization in Coercive Sexuality with the hypothesis that various aspects of sexualization play
an important role in sexual aggression. On the Voyeurism,
Although phallometric assessments do not appear to provide Transvestism, and Exhibitionism scales of the MIDSA, both
strong evidence for a significant role of ‘‘sexualization’’ (i.e., adult and juvenile sex offenders reported higher levels of pa-
sexual preoccupation, sexual compulsivity, hypersexuality, raphilias than community controls (MIDSA, 2008). Whereas
and sexual deviance) in sexually coercive behavior, other data both groups were equivalent to controls on the Fetishism scale,
do support the hypothesis that some aspect of sexual drive or juvenile, but not adult, sex offenders, scored higher than
sexual appetitive behavior is a critical component both in sex- community controls on the Scatologia scale (MIDSA, 2008).
ual aggression (Ellis, 1993; Malamuth, 1998) and in other ‘‘voli- Thus, there is evidence for higher frequency of paraphilias in
tional impairments’’ of sexual behavior (Kafka, 1997, 2003; four out of five MIDSA scales for the juvenile sex offenders
Kafka & Hennen, 2003). A number of investigations have found and three out of five scales for adult sex offenders.
that sexually coercive males have consensual sex at an earlier In light of these data, it is not surprising that the paraphilias
age and have more consensual sex partners than do non-coer- and the high sexualization with which they correlate (Kafka,
cive males (Abbey, McAuslan, & Ross, 1998; Abbey, McAu- 1997; Knight, 1999) have been afforded an important role in
slan, Zawacki, Clinton, & Buck, 2001; Kanin, 1985; Koss & some theories of sexually aggressive behavior against women
Dinero, 1988; Malamuth, Linz, Heavey, Barnes, & Acker, 1995; (Freund, 1988, 1990), and that sexualization plays such a
Malamuth, Sockloskie, Koss, & Tanaka, 1991; Senn, Desmarais, pivotal role in etiological models (Knight & Sims-Knight,
Verberg, & Wood, 2000). Sexual drive and preoccupation have 2003, 2004). The evidence in etiological models suggests a
been found to discriminate sexually coercive from non-coercive covariation between high sexualization and expressive aggres-
males in both community and criminal samples (Knight et al., sion, anger, and sadistic fantasies. In the MASA database de-
2009). Regardless of criminal status, sexually coercive males scribed earlier, the correlations between the PCD scale and
have reported higher levels of sexual drive, greater frequency various aspects of sexualization were found to be high, but not
of sexual behavior, and more sexual deviance on MASA/ as high as the correlation with sadistic fantasy. When sadism
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Arch Sex Behav (2010) 39:419–426 423
and other aspects of offense planning fantasies were partialled, dimensional latent structure for psychopathy (Edens et al.,
smaller, but still significant, correlations between PCD and 2006; Guay et al., 2007; Marcus et al., 2004; Walters, Duncan
sexualization remained, comparable to the partialling results et al., 2007; Walters, Gray et al., 2007; Walters et al., 2008).
reported earlier. As we saw in the brief discussion of the of- Taxometric analyses of the hypersexual/sexualization com-
fense planning scales, the interface of hypersexuality and rape ponent of the circumplex model have not yielded as con-
fantasies is complex and cannot be used by itself to support the vincingly strong support for a dimensional latent distribution,
existence of PCD, independent of sadism. Moreover, deter- but no evidence for a taxonic latent structure has emerged
mining whether differences on sexualization are distributed (Knight, 2009). The preponderance of the evidence supports
taxonically or dimensionally and can be used to identify a a dimensional latent structure for the components of rape and
specific taxon of rapists requires a different analysis strategy argues against the proposition that there exists a paraphilic,
that is addressed in the next section. sexualized, or preferential taxon that could serve as founda-
tion for a distinct diagnostic category.
Harris, Rice, Hilton, Lalumière, and Quinsey (2007) have
The Taxonomic Status of the Components of Rape recently argued that combining precocious and coercive
sexuality indicators with components of the PCL-R identifies
Despite the prevalence of clinical speculation about different a psychopathic sexuality taxon. The analyses they offered in
rapist types and considerable evidence about the heteroge- support of their contention suffered, however, from meth-
neity of rapists, research studies on rapist typologies have odological flaws similar to the previous work of this research
remained infrequent. Only one model, MTC:R3, has detailed group, as well as several problematic inconsistencies in the
classification criteria and has been subjected to empirical specific analyses they presented (see Marcus et al., in press).
scrutiny by several laboratories (for a review, see Knight, Further, their results have not been replicated by an indepen-
2009). Several new studies have been directed at the struc- dent group of researchers (Walters, Marcus, Edens, Knight,
tural problems of MTC:R3 and have supported a revision of & Sanford, 2009). Little weight should be afforded their
the typology into a modified dimensional circumplex struc- contention or the purported analyses they have presented to
ture that both addresses the structural faults of MTC:R3 and support it unless they are able to address these criticisms and
provides a speculative interface of the typology with recent garner independent corroboration. The failure to identify a
research on the developmental antecedents of sexual psychopathic, a hypersexual, or a psychopathic sexuality
aggression against women (Knight, 2009). taxon and the mounting evidence in favor of latent dimen-
The proposed revised model has three components that sionality means that any criteria that were proposed to
account for the variability in rapists: callousness unemo- identify the cutoff for a diagnostic category for PCD would
tionality, antisociality/impulsivity, and hypersexuality/sex- likely be arbitrary. When these findings are coupled with the
ualization. Whereas the first two components are comparable failure to provide any empirical evidence for paraphilic sex-
to the two primary factors of the PCL-R (Hare, 2003), the ual arousal to the coercive characteristics of rape that is
third is similar to the construct of hypersexuality proposed independent of sadism, they do not bode well for either the
by Kafka (2003). A number of studies have used taxometric reliability or validity of any proposed diagnostic criteria.
methods (Meehl, 1995) to address the problem of the latent
distribution of psychopathy and antisociality, which con-
tributes to the first two components of the typological model Conclusions
(Edens, Marcus, Lilienfeld, & Poythress, 2006; Guay, Ru-
scio, Knight, & Hare, 2007; Harris, Rice, & Quinsey, 1994; In summary, although early data on the rape index in phal-
Marcus, John, & Edens, 2004; Skilling, Quinsey, & Craig, lometric assessment seemed to provide potential support for
2001; Vasey, Kotov, Frick, & Loney, 2005; Walters, Brinkley, PCD, recent studies have questioned this conclusion. First,
Magaletta, & Diamond, 2008; Walters, Duncan, & Mitchell- experimental phallometric studies have supported the
Perez, 2007; Walters, Gray et al., 2007). Although the results hypothesis that the differential arousal to sexually coercive
appear mixed, many of the earlier studies unfortunately suf- scenarios in sexually coercive males seems to be explained
fered from significant sampling and methodological weak- better by the failure of coercive and aggressive elements to
nesses that limited their ability to provide a definitive answer inhibit the sexual arousal of these males rather than by sexual
to this question (for the details of these methodological prob- arousal to the coercive elements per se. Second, although the
lems, see Guay et al., 2007; Marcus, Sanford, Edens, Knight, assessment of sadism has remained problematic, the studies
& Walters, in press). More recent studies that have addressed that have used more reliable criteria have found that sadists
these methodological flaws and that have also applied improve- have high rape indices and non-sadistic sexual types of offend-
ments in taxometric evaluation (Ruscio, Haslam, & Ruscio, ers have low indices. The phallometric literature on rapists
2006) have been more consistent, finding strong support for a does not provide convincing evidence that high rape indices
123
424 Arch Sex Behav (2010) 39:419–426
are related to sexual arousal to coercion, as opposed to failure from becoming unconstitutional preventive detention (First &
to inhibit sexual arousal. Moreover, there is no empirical Halon, 2008; Prentky, Janus, Barbaree, Schwartz, & Kafka,
evidence that a sexual response to coercive stimuli can be 2006). Moreover, it is required that it be demonstrated that
differentiated from sexual sadism. This discrimination is an the mental disorder is a likely source of the offender’s sexual
essential component of PCD. Third, offense related fantasies offending. In commitment proceedings for rapists Paraphilia
and cognitions about rape appear to be complex phenomena, NOS, nonconsent has frequently served the role of a sexual-
largely driven by sexual and sadistic motivation. If there were aggression inducing mental disorder, despite the lack of spe-
an independent paraphilic coercive component, its differen- cific criteria for its implementation and the absence of evi-
tiation would be difficult. Fourth, the only typology for rap- dence of its reliability and validity (Prentky et al., 2006). The
ists that had been empirically tested has been revised to a inclusion of PCD would inappropriately legitimize this ‘‘dis-
modified circumplex model with three underlying latent order’’ and grant it the imprimatur of the DSM, which is almost
traits, hypersexuality, callousness/unemotionality, and anti- universally cited by expert witnesses in civil commitment
sociality (Knight, 2009). All methodologically sound taxo- proceedings. The present review indicates that the diagnosis
metric studies on these traits support the hypothesis that the has little empirical support, and it would be a travesty to grant it
components of rape are distributed dimensionally rather than a status that would perpetuate its misuse.
taxonically. There does not appear to be a distinct para-
philic rapist group that coheres naturally into a clearly iden- Acknowledgements I would like to thank Jane Harries, Matthew
King, Elizabeth Saunders, and Judith Sims-Knight for their insightful
tifiable diagnostic entity. Thus, the cutoffs to identify any comments and suggestions on an earlier version of this article. The
paraphilic subgroup of rapists would have to be considered author is an Advisor to the DSM-V Paraphilias subworkgroup of the
an arbitrary boundary created pragmatically to identify rap- Sexual and Gender Identity Disorders Workgroup (Chair, Kenneth J.
ists high in a purported coercive paraphilic dimension. The Zucker, Ph.D.). Reprinted with permission from the Diagnostic and
Statistical Manual of Mental Disorders V Workgroup Reports (Copy-
criteria for classifying these rapists into this alleged diag- right 2009), American Psychiatric Association.
nostic category would have to be considered discretionary.
The Paraphilias subworkgroup for the DSM-V should
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Arch Sex Behav (2010) 39:427–460
DOI 10.1007/s10508-009-9531-5
ORIGINAL PAPER
Queer Diagnoses: Parallels and Contrasts in the History

of Homosexuality, Gender Variance, and the Diagnostic
and Statistical Manual
Jack Drescher

Abstract The American Psychiatric Association (APA) is Similarities and differences in the relationships of homo-
in the process of revising its Diagnostic and Statistical Man- sexuality and gender identity to psychiatric and medical th-
ual (DSM), with the DSM-V having an anticipated publica- inking are elucidated. Following a discussion of these issues,
tion date of 2012. As part of that ongoing process, in May the author recommends changes in the DSM-V and some in-
2008, APA announced its appointment of the Work Group on ternal and public actions that the American Psychiatric Asso-
Sexual and Gender Identity Disorders (WGSGID). The ann- ciation should take.
ouncement generated a flurry of concerned and anxious res-
ponses in the lesbian, gay, bisexual, and transgender (LGBT) Keywords American Psychiatric Association DSM-V
community, mostly focused on the status of the diagnostic Gender variance Gender identity disorder Homosexuality
categories of Gender Identity Disorder (GID) (for both chil- Transgender
dren and adolescents and adults). Activists argued, as in the
case of homosexuality in the 1970s, that it is wrong to label
expressions of gender variance as symptoms of a mental dis-
order and that perpetuating DSM-IV-TR’s GID diagnoses in It was six men of Hindustan
the DSM-V would further stigmatize and cause harm to trans- To learning much inclined,
gender individuals. Other advocates in the trans community Who went to see the Elephant
expressed concern that deleting GID would lead to denying (Though all of them were blind)
medical and surgical care for transgender adults. This review That each by observation
explores how criticisms of the existing GID diagnoses par- Might satisfy the mind.
allel and contrast with earlier historical events that led APA to
The first approached the Elephant
remove homosexuality from the DSM in 1973. It begins with
And happening to fall
a brief introduction to binary formulations that lead not only
Against his broad and sturdy side
to linkages of sexual orientation and gender identity, but also
At once began to bawl:
to scientific and clinical etiological theories that implicitly
‘‘Bless me, it seems the Elephant
moralize about matters of sexuality and gender. Next is a
Is very like a wall’’.
review of the history of how homosexuality came to be re-
moved from the DSM-II in 1973 and how, not long thereafter, The second, feeling of his tusk,
the GID diagnoses found their way into DSM-III in 1980. Cried, ‘‘Ho! What have we here
So very round and smooth and sharp?
To me ‘tis mighty clear
This wonder of an Elephant
J. Drescher (&) Is very like a spear’’.
Department of Psychiatry and Behavioral Sciences,
New York Medical College, 440 West 24th St., Suite 1A, The third approached the animal,
New York, NY 10011, USA And happening to take
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428 Arch Sex Behav (2010) 39:427–460
The squirming trunk within his hands, and Gender Identity Disorders (WGSGID),2 one of 13 Work
Then boldly up and spake: Groups participating in the DSM-V revision process.
‘‘I see,’’ quoth he, ‘‘the Elephant Prior to the WGSGID appointments, media interest in the
Is very like a snake.’’ DSM process had primarily focused on possible conflicts of
interests of psychiatrists with financial ties to the pharma-
The Fourth reached out an eager hand,
ceutical industry (Garber, 2007). However, the announce-
And felt about the knee.
ment of the WGSGID appointments and the group’s charge
‘‘What most this wondrous beast is like
generated a flurry of concerned and anxious responses in the
Is mighty plain,’’ quoth he;
lesbian, gay, bisexual, and transgender (LGBT) community
‘‘‘Tis clear enough the Elephant
and blogosphere, mostly focused on the status of the diagnos-
Is very like a tree!’’
tic categories of Gender Identity Disorder (GID) of Adoles-
The Fifth, who chanced to touch the ear, cence and Adulthood and GID of Childhood (GIDC).3 These
Said: ‘‘E’en the blindest man controversies were subsequently taken up in the LGBT press
Can tell what this resembles most; (Chibbaro, 2008; Osborne, 2008) and, shortly afterwards, the
Deny the fact who can, mainstream media (Carey, 2008) and professional newslet-
This marvel of an Elephant ters (Melby, 2009) began reporting about them as well. The
Is very like a fan!’’ issues LGBT activists raised related to GID and the DSM are
summarized below:
The Sixth no sooner had begun
About the beast to grope, 1. As in the case of homosexuality in the 1970s, it is wrong
Than, seizing on the swinging tail for psychiatrists and other mental health professionals to
That fell within his scope, label expressions of gender variance4 as symptoms of a
‘‘I see,’’ quoth he, ‘‘the Elephant mental disorder and perpetuating DSM-IV-TR’s GID
Is very like a rope!’’ diagnoses in the DSM-V would further stigmatize and
cause harm to transgender individuals, already a highly
And so these men of Hindustan
vulnerable and stigmatized population.
Disputed loud and long,
2. Some members and advocates of the trans community
Each in his own opinion
expressed concern that deleting GID from the DSM-V
Exceeding stiff and strong,
would lead third party payers to deny access to care for
Though each was partly in the right
those transgender adults already struggling with inade-
And all were in the wrong.
quate private and pubic sources of healthcare funding for
John Godfrey Saxe, The Blindmen and the Elephant medical and surgical care.
(1873) 3. Retention of the GID diagnoses would eventually lead to
putting the diagnosis of ‘‘homosexuality,’’ removed from
the DSM-II in 1973, back into the psychiatric manual.
Introduction 4. Clinical efforts with gender variant children aimed at getting
them to reject their felt gender identity and to accept their
natal sex were unscientific, unethical, and misguided. Act-
‘‘We are in a new era in which diagnosis has such social
ivists labeled such efforts a form of ‘‘reparative therapy.’’
and political implications that one is constantly on the
front lines fighting on issues our forebears were spared.’’
Robert Stoller, M.D.1
2
The 13 WGSGID members are Kenneth J. Zucker, Ph.D. (Chair), Irving
The American Psychiatric Association (APA) is in the pro- M. Binik, Ph.D., Ray Blanchard, Ph.D., Lori Brotto, Ph.D., Peggy T.
cess of revising its Diagnostic and Statistical Manual (DSM), Cohen-Kettenis, Ph.D., Jack Drescher, M.D., Cynthia Graham, Ph.D.,
Martin P. Kafka, M.D., Richard B. Krueger, M.D., Niklas Långström,
with the DSM-V having an anticipated publication date of 2012
M.D., Ph.D., Heino F. L. Meyer-Bahlburg, Dr. rer. nat., Friedemann
(Kupfer, First, & Regier, 2002; Phillips, First, & Pincus, 2003). Pfäfflin, M.D., and Robert Taylor Segraves, M.D., Ph.D.
As part of that ongoing process, in May 2008, APA announced 3
In DSM-IV-TR, there is only one diagnosis—GID—with separate
the appointment of the members of the Work Group on Sexual criteria sets for children vs. adolescents/adults.
4
Following Meyer-Bahlburg (2009), ‘‘The nomenclature in the area of
gender variations continues to be in flux, in regard to both the descriptive
terms used by professionals, and, even more so, the identity terms adopt-
ed by persons with GIV [Gender-Identity-Variants].’’ Where possible,
this author will use the term ‘‘gender variance’’ to refer to individuals
1
Cited in Bayer (1981, p. 10). with gender atypical behavior or self presentations.
123
Arch Sex Behav (2010) 39:427–460 429
5. Internet bloggers and petitioners widely circulated ad homi- What is normal sexuality [or normal gender]? What is
nem accusations and attacks against individual members of the role of sexuality [or the role of gender] in human
the WGSGID who were characterized as prejudiced against existence? Do the brute requirements of species’ sur-
transgender individuals (i.e., transphobic).5 Some profes- vival compel an answer to the question of whether ho-
sionals petitioned the APA to ‘‘balance’’ the work group mosexuality [or whether gender variance] is a disorder?
appointments with more ‘‘trans positive’’ members.6 Fears How should social values influence psychiatry and help
were raised that these individuals would use their position to to define the concept of mental illness? What is the app-
influence the Work Group in ways that would further exac- ropriate scope of a nosology of psychiatric disorders?
erbate stigma and prejudice against the trans community. How should conflicts over such issues be resolved?
How should the opposing principles of democracy and
There is no factual basis to the rumors that APA, which
authority be brought to bear in such matters? (Bayer,
issued a 2005 position statement supporting civil marriage
1981, p. 4)
equality for gay people,7 might restore homosexuality to the
DSM nor have these assertions been made by anyone affili- As in the case of homosexuality, arguments for removal of
ated with APA or the DSM process (Osborne, 2008). What the ‘‘trans diagnoses’’ include societal intolerance of differ-
constitutes a reparative therapy is addressed briefly later in ence, the human cost of diagnostic stigmatization, using the
this review. Meyer-Bahlburg (2009), in a related DSM re- language of psychopathology to describe what some consider
view, takes up the issue of how medical treatment of gender to be normal behaviors and feelings and, finally, inappropri-
variance might be conceptualized with or without the GID ately focusing psychiatric attention on individual diversity
diagnosis in greater detail. Also in related reports, Cohen- rather than opposing the social forces that oppress sexual and
Kettenis and Pfäfflin (2009) and Zucker (2009) review the gender nonconformity.9
diagnostic criteria of the existing GID diagnoses. Although In consideration of the question of removal versus reten-
this author questions the utility of ad hominem and ad fem- tion, this review begins with a brief introduction to binary
inam attacks by activists opposed to researchers with whom formulations that lead not only to linkages of sexual orien-
they disagree, that is a discussion for another paper.8 tation and gender identity, but also to scientific and clinical
The bulk of this report explores how criticisms of the exist- etiological theories that implicitly moralize about matters of
ing GID diagnoses compare with earlier historical events that sexuality and gender. Next is a review of the history of how
led APA to remove homosexuality from the DSM in 1973. homosexuality came to be removed from the DSM-II in 1973
The definitive chronicle of events leading up to that decision and how, not long thereafter, the GID diagnoses found their
is Bayer’s (1981) Homosexuality and American Psychiatry: way into DSM-III in 1980. Although the DSM-IV-TR diag-
The Politics of Diagnosis in which he lays out some ‘‘deep nosis of Transvestic Fetishism also falls under the transgen-
and fundamental questions’’ regarding the relationship be- der umbrella—and the history of that diagnosis is worthy of
tween psychiatry and homosexuality that were heatedly de- similar review—this paper confines its discussion to the his-
bated four decades ago. As the added comments in brackets tory and issues surrounding the GID diagnoses and their intro-
below indicate, today society is debating similar questions duction to the psychiatric nomenclature in the DSM-III.10
about gender as well: This paper goes on to elucidate some similarities and
differences in the relationships of homosexuality and gen-
der identity to psychiatric and medical thinking. Although
5
For example, see http://www.thepetitionsite.com/2/objection-to-dsm-v-
this paper primarily focuses on adolescent and adult GID, it
committee-members-on-gender-identity-disorders; retrieved February briefly addresses the question of whether efforts to convert a
9, 2009. child’s gender identity (as opposed to an individual’s sexual
6
For example, see http://professionals.gidreform.org/samples.html; orientation) are a form of reparative therapy. This is followed
retrieved July 10, 2009. by a discussion leading to this author’s recommendations for
7
Retrieved November 9, 2008 from http://www.psych.org/Departments/ changes in the DSM-V in particular as well as some internal
EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/
200502.aspx. organizational and public policy actions that should be taken
8
Several years ago, members of the LGBT community protested the con- by the American Psychiatric Association.
tent of Northwestern University’s J. Michael Bailey’s (2003) book, The 9
Man Who Would be Queen. While there were activists who primarily See Karasic and Drescher (2005).
10
criticized the author’s arguments regarding transgenderism, some activ- In a classic text on the subject, Benjamin’s (1966) The Transsexual
ists attacked Bailey’s character, reputation, and family members. Dreger Phenomenon takes pains to distinguish transvestitism from transsexu-
(2008) has summarized an account of those events. Critics of Dreger’s alism. The current DSM-IV-TR diagnosis of ‘‘transvestic fetishism,’’ in
account of those events include Bettcher (2008), Gagnon (2008), Lane one form or another, has been found in all editions of the DSM. It is be-
(2008), Mathy (2008), McCloskey (2008), and Nichols (2008) among yond the scope of this paper to go into that history, although, as Benjamin
others. Also see Archives of Sexual Behavior, Volume 37(3), 2008 for a (1966) noted, touching upon transvestitism can be helpful in clarifying
broad range of discussions of the Dreger article. one’s understanding of transsexualism.
123
430 Arch Sex Behav (2010) 39:427–460
Although the author is a member of the DSM-V Work frame of reference. Once regarded as synonymous, it is only
Group on Sexual and Gender Identity Disorders, this paper and relatively recently that sexual orientation (defined as an indi-
its recommendations do not necessarily represent the positions vidual’s erotic response tendency or sexual attractions) and
of either the Work Group or of the APA. It is just the author’s gender identity (defined as one’s sense of oneself as being either
own perspective. The aim of this review is to further discussion male or female) have been regarded as separate categories.
of substantive issues in the debates surrounding possible re- History offers many examples of this conflation. For exam-
moval, modification or retention of the DSM GID diagnoses. ple, in the mid-19th century, Ulrichs (1994) hypothesized that
In preparing this review, this author was unable to find any some men were born with a woman’s spirit trapped in their
one perspective that adequately tied together the disparate bodies. He believed these men constituted a third sex and
threads of understanding gender. The issues involved are com- named them urnings.13 While historians of homosexuality
plex and do not lend themselves to easy solutions. The author’s unremarkably and routinely seem to regard Ulrichs’ urnings as
own efforts to fashion such a synthesis left him pondering homosexual men (Bullough, 1979; Chauncey, 1994; Green-
anew the proverbial blind men inadequately describing an ele- berg, 1988), a female spirit in a male body bears a narrative
phant by touching just one of its body parts. In fact, many of the kinship with 20th century theories of transsexualism. Like
authors cited in this review have put forward some element of many theories about homosexuality and transgenderism, Ul-
truth, albeit a partial one. As in the case of the blind men and the richs drew upon longstanding gender beliefs, employing im-
elephant, the metaphors evoked by the parts offer only a partial plicit cultural ideas about the ‘‘essential’’ qualities of men and
understanding of the whole of gender variance, gender diag- women (Drescher, 1998a, 2007; Drescher & Byne, 2009).
noses and the social construction of gender. In acknowledg- People express gender beliefs, their own and those of the
ment of gender’s multiplicity, this author makes no claim of culture in which they live, in everyday language as they either
having a more acute vision than others who have theorized or indirectly or explicitly accept and assign gendered meanings to
written about the matter. Hopefully, readers will accept this what they and others do, think, and feel. Gender beliefs touch
limitation and be patient as this review takes them through the upon almost every aspect of daily life, including such mundane
subject’s complexity. concerns as the kind of shoes men should wear or ‘‘deeper’’
questions of masculinity such as whether men should openly
cry. Gender beliefs are embedded in questions about the kind
Gender Binaries, Sexual Orientation, and Gender of career a woman should pursue and, at another level of dis-
Variance course, what it would mean if a professional woman were to
forego rearing children or pursue her career more aggressively
It is not altogether surprising that questions about the proper than a man. ‘‘Real men’’ and ‘‘real girls’’ are powerful cultural
place of gender variance in a psychiatric manual would re- myths with which everyone must contend.
semble those regarding the placement of sexual orientation as Gender beliefs draw upon gender binaries that usually
well. ‘‘Both historically and cross-culturally, transgender refer to a most ancient one, that of male/female, but can also
people have been the most visible minority among people include the 19th century binary of homosexuality/heterosex-
involved in same-sex sexual practices. As such, transgen- uality and, perhaps in the future, the emerging 21st century
dered [sic]11 people have been emblematic of homosexuality binary of transgender/cisgender. Furthermore, these binaries
in the minds of most people’’ (Devor, 2002, p. 5). In addition, are not confined to popular usage. Many scientific studies of
‘‘atypical gender behavior’’ is not an infrequent finding in the homosexuality contain implicit (and often explicit) binary
histories of gay men and women (Bell, Weinberg, & Ham- gender beliefs as well. For example, the intersex hypothe-
mersmith, 1981; Mathy & Drescher, 2009). sis of homosexuality (Byne, 1995; Drescher & Byne, 2009)
Many cultures routinely conflate homosexuality with trans- maintains that the brains of homosexual individuals exhibit
gender identities because they rely upon several beliefs that characteristics that would be considered more typical of the
use conventional heterosexuality and cisgender12 identities as a other sex. The essentialist gender belief implicit in intersex
hypotheses is that an attraction to women is a masculine trait,
11
The use of ‘‘transgendered’’ as an adjective has begun to fall out of fa- which in the case of Freud (1920) led to his theorizing about
vor and has been replaced by ‘‘transgender,’’ as in ‘‘transgender people.’’
12
lesbians as having a masculine psychology, while biological
Historically, the term ‘‘homosexual’’ preceded and necessitated the
researchers have presumed that gay men have brains that
creation of the term ‘‘heterosexual’’; the latter term emerged as a more
specific signifier of what people used to think of as ‘‘normal.’’ Similarly,
members of the transgender community have coined the term ‘‘cisgen-
der’’ to describe those whose psychological gender is concordant with Footnote 12 continued
their anatomical sex and who usually think of their gender identity as just (http://en.wikipedia.org/wiki/Cisgender). Some trans writers (Serano,
‘‘normal.’’ ‘‘The word has its origin in the Latin-derived prefix cis, 2007) prefer cissexual rather than cisgender.
13
meaning ‘on the same side’ as in the cis–trans distinction in chemistry. Ulrichs defined a woman who we would today call a lesbian as urn-
In this case, ‘cis’ refers to the unity of a gender identity with a gender role’’ ingin, a man’s spirit trapped in the body of a woman.
123
Arch Sex Behav (2010) 39:427–460 431
more closely resemble those of women (LeVay, 1991) or are century, intersex infants,16 even in the absence of medical
recipients of extra fragments of their mothers’ X (female) necessity, have been routinely subjected to surgery for the
chromosomes (Hamer & Copeland, 1994).14 purposes of ‘‘confirming’’ an earlier assignment to either
Gender beliefs usually only allow for the existence of two male or female genders (Colapinto, 2000; Diamond & Sig-
sexes.15 To maintain this gender binary, most cultures tra- mundson, 1997; Dreger, 1998, 1999; Fausto-Sterling, 2000;
ditionally insisted that every individual be assigned to the Kessler, 1998; Money, Hampson, & Hampson, 1955a, 1955b,
category of either man or woman at birth and that individuals 1957).
conform to the category to which they have been assigned As the case of Iran illustrates, it is common when entering
thereafter (Drescher, 2007). The categories of ‘‘man’’ and the realms of gender and sexuality to encounter another form
‘‘woman’’ are considered to be mutually exclusive. Iran, in of binary thinking: ‘‘morality tales’’ about whether certain
contrast to Western beliefs and practices, offers a dramati- kinds of thoughts, feelings, or behaviors are ‘‘good or bad’’ or,
cally startling example of how a contemporary society equip- in some cases, whether they are ‘‘good or evil’’ (Drescher,
ped with sufficient modern technology can reinforce its own 1998a, 2002a). The good/bad binary is not confined to religion
binary perspectives. While homosexuality is illegal there, it is alone as the language of morality is inevitably found, for
estimated that about 150,000 transsexuals live in Iran, which example, in theories about the ‘‘causes’’ of homosexuality. For
hosts more sex-reassignment surgery (SRS) than any nation in the absence of certitude about homosexuality’s ‘‘etiology,’’
besides Thailand: binary gender beliefs and their associated moral underpin-
nings frequently play a role in theories about the causes and/or
Explaining the apparent paradox, one Muslim cleric says
meanings of homosexuality. When one recognizes the narra-
that while homosexuality is explicitly outlawed in the
tive forms of these theories, some of the moral judgments and
Qur’an, sex-change operations are not. They are no more
beliefs embedded in each of them become clearer.
an affront to God’s will than, for example, turning wheat
into flour and flour into bread. So while homosexuality is
punishable by death, sex-change operations are present-
Homosexuality as Psychiatric Diagnosis
ed as an acceptable alternative—as a way to live within a
set of strict gender binaries, as a way to, well, live like
Nowhere are the moral implications of etiological theories
others. The tragic aspect comes through in discussions
more apparent than in the modern history of homosexuality’s
with patients and their reluctant parents in the waiting
status as a psychiatric diagnosis. As noted elsewhere (Dre-
room of Tehran’s pre-eminent sex-change surgeon, Dr.
scher, 1998a, 2002a), it is possible to formulate a descriptive,
Bahram Mir Jalali, where it becomes clear that some feel
empirical typology of etiological theories of homosexual-
pressured, not free, to become transsexuals. Asked if he
ity17 in which they generally fall into three broad categories:
would be preparing for surgery were he living outside
normal variation, pathology, and immaturity.18
Iran, one young man says, ‘‘No. I wouldn’t do it. I
wouldn’t touch God’s work.’’ (Ellison, 2008) 1. Theories of normal variation treat homosexuality as a
phenomenon that occurs naturally. Such theories typi-
Rigid gender beliefs often flourish in fundamentalist, reli-
cally regard homosexual individuals as born different,
gious communities where any information or alternative ex-
but it is a natural difference, like left-handedness. The
planations that might challenge implicit and explicit assump-
contemporary cultural belief that people are ‘‘born gay’’
tions are unwelcome. Iran’s implementation of coercive SRS
to prevent some of its gay citizens from practicing homosex-
uality is an extreme application of a culture’s binary gender 16
Historically referred to as ‘‘hermaphroditism’’ and later as ‘‘intersex,’’
beliefs. Yet this cultural need to maintain gender binaries can
the recent term ‘‘disorders of sex development’’ (DSD), like ‘‘gender
also be found in the West where, since the last half of the 20th identity disorder,’’ has also divided intersex activists between those who
see this medical terminology as stigmatizing and those who see it as
necessary for providing informed treatment.
14 17
‘‘But every once in a while…the X and Y chromosomes get jumbled The exact ‘‘causes’’ of heterosexuality are also unknown, but as a
up, and this little strip of DNA from a Y chromosome is ‘mistakenly’ dominant cultural narrative regarded as ‘‘normal,’’ heterosexuality rare-
passed to a daughter (or a bit of the X goes to a son). That means boys are ly requires explanation. Yet as Freud (1905) noted, ‘‘from the point of
getting a tiny bit of ‘female’ chromosome and girls are getting a bit of a view of psycho-analysis the exclusive sexual interest felt by men for
‘male’ chromosome. This raised the intriguing possibility that a genetic women is also a problem that needs elucidating and is not a self-evident
crossover between the male and female sex chromosomes is related to fact based upon an attraction that is ultimately of a chemical nature (pp.
the behavioral ‘crossover’ between heterosexuality and homosexual- 145–146n).
ity’’ (Hamer & Copeland, 1994, p. 128). 18
Among the key words in the morality tales embedded in etiological
15
There are exceptions, as in Plato’s Symposium and some Native theories are ‘‘social benefit’’ and ‘‘social harm,’’ ‘‘good and evil,’’ ‘‘health
American cultures (Williams, 1986). Also see Fausto-Sterling (1992, and illness,’’ ‘‘adaptive and maladaptive,’’ ‘‘holy and sinful,’’ or ‘‘mature
1993, 2000) for a scientist’s thoughtful criticisms of gender binaries. and childish.’’
123
432 Arch Sex Behav (2010) 39:427–460
is a normal variation theory.19 As these theories equate Germany’s Paragraph 175 that criminalized male homosexual
the normal with the natural, they define homosexuality as behavior (Katz, 1995). Kertbeny put forward his theory that
good (or, at baseline, neutral). Such theories see no place homosexuality was inborn and unchangeable, arguments that it
for homosexuality in a psychiatric diagnostic manual. was a normal variation, as a counterweight against the condemna-
2. Theories of pathology regard adult homosexuality as a tory moralizing attitudes that led to the passage of sodomy laws.
disease, a condition that deviates from ‘‘normal,’’ hetero- Richard von Krafft-Ebing, a German psychiatrist, offered a
sexual development. Atypical gender behavior or feelings theory of pathology that described homosexuality as a ‘‘degen-
are symptoms of a ‘‘disease’’ to which mental health pro- erative’’ disorder. Adopting Kertbeny’s terminology, but not
fessionals need to attend. These theories hold that some his normalizing beliefs, Krafft-Ebing’s (1965) Psychopathia
internal defect or external pathogenic agent causes homo- Sexualis viewed unconventional sexual behaviors through the
sexuality and that such events can occur pre- or postna- lens of 19th century Darwinian theory: all non-procreative sex-
tally (intrauterine hormonal exposure, excessive mother- ual behaviors, now subject to medical scrutiny, were regarded
ing, inadequate or hostile fathering, sexual abuse). Theo- as forms of psychopathology. In an ironic twist of the modern
ries of pathology tend to view homosexuality as either bad ‘‘born gay’’ theory, Krafft-Ebing believed that although one
or as a sign of a defect and some of these theorists are quite might be born with a homosexual predisposition, such inclina-
open about their belief that homosexuality is evil.20 tions should be considered a congenital disease. Krafft-Ebing
3. Theories of immaturity regard expressions of homosex- was influential in disseminating among the medical and sci-
ual feelings or behavior at a young age as a normal step entific communities both the term ‘‘homosexual’’ as well as its
toward adult heterosexuality. Ideally, homosexuality is a author’s view of homosexuality as a psychiatric disorder.21
passing phase that one outgrows. However, as a ‘‘devel- Psychopathia Sexualis would presage many of the patholo-
opmental arrest,’’ adult homosexuality is equated with gizing assumptions regarding human sexuality in psychiatric
stunted growth. Those who hold these theories tend to diagnostic manuals of the mid-20th century.
regard immaturity as relatively benign, or at least not In contrast to Krafft-Ebing, Havelock Ellis (1905), a British
as ‘‘bad’’ compared to those theorists of pathology who sexologist, considered homosexuality a normal variation of
have a tendency to emphasize the potentially malignant sexual expression. A normative view was also the position of
meanings of homosexuality. the German homophile movement led by openly homosexual
physician and sex researcher, Magnus Hirschfeld (1914), the
Throughout history, discourse about homosexuality has been
major torchbearer in his time of Ulrich’s (1994) 19th century
tied to cultural values. Thus, unsurprisingly, official pronounce-
third sex theories.22 In contrast to Ellis and Hirschfeld’s the-
ments on the meanings of same-sex behaviors were once pri-
ories of normal variation and Krafft-Ebing’s theory of pathol-
marily the province of religions, many of which deemed homo-
ogy, Freud put forward a third kind of narrative, a theory of
sexuality to be ‘‘bad.’’ However, as 19th century Western culture
immaturity, that would also find its way into the popular
shifted power from religious to secular authority, homosexuality
imagination.
received increased scrutiny from, among others, the fields of law,
According to Freud (1905), as everyone is born with bisexual
medicine, psychiatry, sexology, and human rights activism. In
tendencies, expressions of homosexuality can be a normal phase
1869, Hungarian journalist Károli Mária Kertbeny first coin-
of heterosexual development. His belief in innate bisexuality
ed the terms ‘‘homosexual’’ and ‘‘homosexuality’’ in a political
did not allow for the possible existence of Hirschfeld’s third sex:
treatise against Paragraph 143, a Prussian law later codified in
‘‘Psychoanalytic research is most decidedly opposed to any att-
19
These theories say that gay people are born different, but their dif- empt at separating off homosexuals from the rest of mankind as
ferences are natural and intrinsic to who they are. Today, left-hand- a group of special character’’ (p. 145n).23 Further, Freud argued
edness is an apt analogy, as its presence in a minority of people is not
defined as illness, although being left-handed may have disadvantages. 21
Yet, in the past, being left-handed did lead to social opprobrium (the Psychopathia Sexualis also attracted innumerable lay readers who
word sinister is derived from a Latin root connoting the left side) and were intrigued, and sometimes felt recognized, to finally read about
historically, analogous to gay men, left-handed children were often experiences analogous to their own. Such readers often submitted their
treated as if they were abnormal and cured of their antisocial habit by own accounts to Krafft-Ebing and, partly for this reason, the volume
forcing them to write right-handed. grew larger in each subsequent edition (J. Kerr, personal communica-
20 tion, July 11, 2009).
The psychiatrist Edmund Bergler (1956) infamously wrote in a book 22
for general audiences, ‘‘I have no bias against homosexuals; for me they Hirschfeld would also help some of his patients obtain early access to
are sick people requiring medical help… Still, though I have no bias, I sex reassignment surgery (Denny, 2002).
23
would say: Homosexuals are essentially disagreeable people, regardless Freud’s earlier diplomatic rebuke of Hirschfeld’s theory can be
of their pleasant or unpleasant outward manner…[their] shell is a compared with his more contemptuous assessment several years later:
mixture of superciliousness, fake aggression, and whimpering. Like all ‘‘The mystery of homosexuality is therefore by no means so simple as it
psychic masochists, they are subservient when confronted with a stron- is commonly depicted in popular expositions—‘a feminine mind, bound
ger person, merciless when in power, unscrupulous about trampling on a therefore to love a man, but unhappily attached to a masculine body; a
weaker person’’ (pp. 28–29). masculine mind, irresistibly attracted by women, but, alas! imprisoned
123
Arch Sex Behav (2010) 39:427–460 433
that homosexuality could not be a ‘‘degenerative condition’’ as sexual into a heterosexual does not offer much more prospect
Krafft-Ebing maintained because, among other reasons, it was of success than the reverse, except that for good practical
‘‘found in people whose efficiency is unimpaired, and who are reasons the latter is never attempted’’ (p. 151). In contrast, the
indeed distinguished by specially high intellectual development next generation of analysts viewed efforts to cure homosex-
and ethical culture’’ (p. 139).24 Instead, Freud saw expressions uality as akin to treating other forms of unconscious anxiety.
of adult homosexual behavior as caused by ‘‘arrested’’ psycho- Although retaining elements of Freud’s immaturity narra-
sexual development. tive, focusing on presumed preoedipal ‘‘causes’’ of homosex-
In support of that claim, he wrote several papers attributing uality (Lewes, 1988), mid-20th century analysts regarded the
the homosexuality of patients and historic figures to family ‘‘homosexual’s’’ development arrest less benignly than did
dynamics. For example, in Leonardo da Vinci and a Memory Freud. Their pathologizing theories provided a rationale for
of His Childhood (Freud, 1910), he attributed the artist’s claims of ‘‘cure.’’ However, despite their therapeutic optimism,
homosexuality to prolonged mothering and an absent father. most of their efforts appeared to have been unsuccessful. In a
In The Psychogenesis of a Case of Homosexuality in a Wo- rare, controlled analytic study, Bieber et al. (1962) treated 106
man (Freud, 1920), he argued that his female patient, disap- homosexual men. They claimed a 27% ‘‘cure’’ rate with psy-
pointed by the birth of a younger brother during the pubertal choanalysis, but when challenged a decade later to produce a
resurgence of her Oedipus complex, turned away from her ‘‘cured’’ patient, they were unable to do so (Tripp, 1987).27
father and from men in general. ‘‘She foreswore her wom- Although practitioners of aversion therapy in the 1960s also
anhood and sought another goal for her libido…she changed claimed ‘‘cures,’’ by the 1970s behavioral therapists admitted
into a man and took her mother in place of her father as a love that few of their patients managed to stay ‘‘converted’’ for very
object’’ (p. 215). Toward the end of his life, Freud (1935) long (Bancroft, 1974; Davison, 1976).
wrote ‘‘Homosexuality is assuredly no advantage, but it is While psychiatrists, physicians, and psychologists were
nothing to be ashamed of, no vice, no degradation; it cannot trying to ‘‘cure’’ and change homosexuality, sex researchers
be classified as an illness; we consider it to be a variation of of the mid-20th century instead studied a wider spectrum of
the sexual function, produced by a certain arrest of sexual individuals that included non-patient populations. Psychia-
development’’ (p. 423).25 trists and other clinicians inevitably drew conclusions from a
Yet, by the early 20th century, psychiatrists mostly regarded biased sample of patients seeking treatment for their homo-
homosexuality as pathological. After Freud’s death in 1939, sexuality or other difficulties and then wrote up findings of
many psychoanalysts of the next generation would come to echo this self-selected group as case reports. Sexologists, on the
that position as well. With a few notable exceptions, they would other hand, went out and recruited large numbers of non-
claim a new and improved understanding of homosexuality and patient subjects for their studies.
then proffer psychoanalytic ‘‘cures’’ that had eluded their field’s Most prominent among those studies was the research of
founder. They based their views on the theories of Rado (1940, Kinsey and his collaborators: Sexual Behavior in the Human
1969), a Hungarian émigré to the United States whose theories Male (Kinsey, Pomeroy, & Martin, 1948) and Sexual Behavior
had a significant impact on American psychiatric and psycho- in the Human Female (Kinsey, Pomeroy, Martin, & Gebhard,
analytic thought in the mid-twentieth century.26 Rado claimed, 1953). The Kinsey reports surveyed thousands of people and
in contrast to Freud, that there was no such thing as either innate found homosexuality to be more common in the general pop-
bisexuality or normal homosexuality. Heterosexuality was the ulation than was generally believed. Kinsey’s now-famous
only biological norm and homosexuality a ‘‘phobic’’ avoidance ‘‘10%’’ statistic, today believed to be closer to 1–4% (Laumann,
of the other sex caused by inadequate parenting. Gagnon, Michael, & Michaels, 1994),28 was sharply at odds
Freud had pessimistically written in a 1920 case report, with psychiatric claims of the time that homosexuality was
‘‘In general, to undertake to convert a fully developed homo- extremely rare in the general population. Ford and Beach’s
(1951) Patterns of Sexual Behavior, a study of diverse cultures
Footnote 23 continued and of animal behaviors, confirmed Kinsey’s view that homo-
in a feminine body.’….If [psychoanalytic] findings are taken into ac-
sexuality was more common than psychiatry maintained and
count, then, clearly, the supposition that nature in a freakish mood
created a ‘third sex’ falls to the ground’’ (Freud, 1920, pp. 170–171).
24
Freud (1905), in The Three Essays, described Krafft-Ebing’s 27
Responding to Tripp’s challenge of Bieber’s claims of therapeutic
‘‘pathological approach to the study of inversion’’ as being ‘‘displaced success, rather than producing a patient, Bieber filed an ethics complaint
by the anthropological. The merit for bringing about this change is due to with the American Psychological Association for impugning his ‘‘scien-
[Ivan] Bloch, who has also laid stress on the occurrence of inversion tific honesty and credibility.’’ The Committee on Scientific and Pro-
among the civilizations of antiquity’’ (p. 139n). fessional Ethics and Misconduct found no evidence of unethical be-
25
Freud also signed a 1930 petition calling for decriminalization of havior (Tripp, 1987, p. 287).
homosexuality in Germany and Austria (Abelove, 1993). 28
In 1903, Hirschfeld surveyed 3,000 students in a technical school and
26
Rado was the founder of the Columbia Center for Psychoanalytic found 1.5% of the students identified as homosexual and 4.5% as bisex-
Training and Research in New York City. uals (Pfäfflin, 1997).
123
434 Arch Sex Behav (2010) 39:427–460
that it was found regularly in nature.29 In the late 1950s, Hooker Fryer, M.D. Fryer appeared as Dr. H Anonymous, a ‘‘homo-
(1957), a psychologist, published a study that refuted psychiatric sexual psychiatrist’’ who, given the realistic fear of adverse
beliefs of her time, as her study failed to find more signs of professional consequences for coming out at that time, dis-
psychological disturbances in a group of non-patient homo- guised his true identity from the audience and spoke of the
sexual men compared to non-patient heterosexual controls.30 discrimination gay psychiatrists faced in their own profes-
American psychiatry, influenced at the time by psycho- sion (Gittings, 2008; Scasta, 2002).
analytic ego psychology, mostly ignored this growing body As these protests and panels took place, APA also embarked
of sex research and, in the case of Kinsey, expressed extreme upon an internal deliberative process of considering the ques-
hostility to findings that contradicted their own theories (Lewes, tion of whether homosexuality should remain a psychiatric
1988). This was the general state of affairs when, in 1952, diagnosis. At a session of the 1973 APA annual meeting, par-
APA published its first edition of the Diagnostic and Statis- ticipants favoring and opposing removal debated the ques-
tical Manual (DSM-I), listing all the conditions psychiatrists tion, ‘‘Should Homosexuality be in the APA Nomenclature?’’
then considered to be a mental disorder. DSM-I classified and shortly thereafter those proceedings were published in
‘‘homosexuality’’ as a ‘‘sociopathic personality disturbance.’’ the APA’s American Journal of Psychiatry (Stoller et al.,
In DSM-II, published in 1968, homosexuality was reclassi- 1973). The Nomenclature Committee, APA’s scientific body
fied as a ‘‘sexual deviation.’’ However, by 1970, the scientific addressing this issue, also wrestled with the question of what
research arguing for a non-pathological view of homosexu- constitutes a mental disorder. Spitzer (1981), who chaired a
ality was dramatically brought to the attention of the APA. subcommittee looking into the issue, ‘‘reviewed the charac-
As Bayer (1981, 1987) has noted, factors both outside and teristics of the various mental disorders and concluded that,
within APA would lead to a reconceptualization of homo- with the exception of homosexuality and perhaps some of the
sexuality’s place in the diagnostic manual. In addition to the other ‘sexual deviations,’ they all regularly caused subjective
research findings from outside psychiatry, there was a grow- distress or were associated with generalized impairment in
ing anti-psychiatry movement (Szasz, 1960) and an emerging social effectiveness of functioning’’ (p. 211). Having arrived
generational changing of the guard within APA comprised at this novel definition of mental disorder, the Nomenclature
of younger leaders urging the organization to greater social Committee agreed that homosexuality per se was not one
consciousness (Drescher, 2006a). A very few psychoanalysts (Bayer, 1981; Drescher, 2003; Drescher & Merlino, 2007;
like Marmor (1965) were also taking issue with psychoana- Hire, 2002; Rosario, 2003; Sbordone, 2003; Spitzer, 1981;
lytic orthodoxy regarding homosexuality (Drescher, 2006b; Stoller et al., 1973). Several other APA committees and delib-
Rosario, 2003). However, the most significant catalyst for erative bodies then reviewed their work and approved that
diagnostic change was gay activism. In the wake of the 1969 decision. Finally, in December 1973, APA’s Board of Trust-
Stonewall riots in New York City (Duberman, 1994), gay and ees (BOT) voted to remove homosexuality from the DSM.
lesbian activists, believing psychiatric theories to be a major Psychiatrists from the psychoanalytic community, object-
contributor to antihomosexual social stigma, disrupted the ing to the decision, petitioned APA to hold a referendum in
1970 and 1971 annual meetings of the APA. which the entire membership was asked to vote either in sup-
The protests were successful in getting organized psychi- port of or against the BOT decision (Bieber, 1987; Socarides,
atry’s attention and led to unprecedented and groundbreaking 1995). The decision to remove was upheld by a 58% majority
educational panels at the next two annual APA meetings. A of voting members.31 The declassification of homosexuality
1971 panel, entitled ‘‘Gay is Good,’’ featured gay activists was accompanied by APA issuing a position statement32
Frank Kameny and Barbara Gittings explaining to psychia- (Bayer, 1981; Drescher, 2006a; Lynch, 2003) which became
trists, many who were hearing this for the first time, the stigma the first of many APA position statements supporting civil
caused by the ‘‘homosexuality’’ diagnosis (Gittings, 2008; rights protections for gay people:
Kameny, 2009; Silverstein, 2009). Kameny and Gittings re-
Whereas homosexuality in and of itself implies no
turned to speak at the 1972 meeting, this time joined by John
impairment in judgment, stability, reliability, or voca-
29
For more contemporary biological studies of homosexuality in tional capabilities, therefore, be it resolved that the
animals, see Bagemihl (1999). For more contemporary anthropological American Psychiatric Association deplores all public
views regarding homosexuality and transgenderism see Herdt (1994).
31
30
Hooker compared 30 gay men with 30 heterosexual controls using It should be noted that psychiatrists did not vote, as reported in the
the TAT, the Make-a-Picture-Story test (MAPS test), and the Rorschach popular press, on whether homosexuality should remain in the diagnostic
inkblot test. Following Hooker, Siegelman (1972) compared 84 homo- manual. What APA members voted on was to either ‘‘favor’’ or ‘‘oppose’’
sexual women to 113 heterosexual control and found the former ‘‘to be the APA Board of Trustees decision and, by extension, the scientific pro-
as well adjusted as the latter.’’ In a more extensive review of the liter- cess they had set up to make the determination (Bayer, 1981, p. 148).
32
ature, Riess (1980) concluded ‘‘there are no psychological test tech- The statement was largely based on language formulated by Richard
niques which successfully separate homosexual men and women from Pillard and Lawrence Hartmann and their pioneering work on this issue
heterosexual comparisons’’ (p. 308). within the Northern New England Psychiatric Society (Bayer, 1981).
123
Arch Sex Behav (2010) 39:427–460 435
and private discrimination against homosexuals in such diagnosis regarded homosexuality as an illness if an individual
areas as employment, housing, public accommodations, with same-sex attractions found them distressing and wanted to
and licensing, and declares that no burden of proof of change (Spitzer, 1981; Stoller et al., 1973). The new diagnosis
such judgment, capacity, or reliability shall be placed on served the purpose of legitimizing the practice of sexual con-
homosexuals greater than that imposed on any other version therapies (and presumably justified insurance reim-
persons. Further, the APA supports and urges the bursement for those interventions as well), even if homosex-
enactment of civil rights legislation at local, state, and uality per se was no longer considered an illness. The new
federal levels that would insure homosexual citizens the diagnosis of SOD also allowed for the unlikely possibility that a
same protections now guaranteed to others. Further, the person unhappy about a heterosexual orientation could seek
APA supports and urges the repeal of all legislation treatment to become gay.35
making criminal offenses of sexual acts performed by In 1980, DSM-III dropped SOD and in its place substituted
consenting adults in private.33 ‘‘Ego Dystonic Homosexuality’’ (EDH) (Spitzer, 1981). How-
ever, it was obvious to psychiatrists more than a decade later
Thus ended the American classification of homosexuality
that the inclusion first of SOD, and later EDH, had been the
per se as an illness. Within two years, other major mental health
result of earlier political compromises and that neither diag-
professional organizations, including the American Psycho-
nosis met the definition of a disorder in the new nosology
logical Association, the National Association of Social Work-
(Mass, 1990a, 1990b). Otherwise, all kinds of identity distur-
ers, and the Association for Advancement of Behavior Therapy,
bances could be considered psychiatric disorders. ‘‘Should
endorsed the APA decision.
people of color unhappy about their race be considered men-
This did not, however, mean that APA was endorsing a
tally ill?’’ critics asked. What about short people unhappy
normal variant model of homosexuality:
about their height? Why not ego-dystonic masturbation (Mass,
If homosexuality per se does not meet the criteria for a 1990a)? As a result, ego-dystonic homosexuality was removed
psychiatric disorder, what is it? Descriptively, it is one from the next revision, DSM-III-R, in 1987 (Krajeski, 1996).
form of sexual behavior. Our profession need not now In so doing, the APA implicitly accepted a normal variant view
agree on its origin, significance, and value for human of homosexuality in a way that had not been possible 14 years
happiness when we acknowledge that by itself it does not earlier.
meet the requirements for a psychiatric disorder. Simi- Other diagnostic systems would eventually follow suit. In
larly, by no longer listing it as a psychiatric disorder we 1992, the World Health Organization (WHO, 1992) removed
are not saying that it is ‘‘normal’’ or as valuable as het- ‘‘homosexuality’’ from the Tenth Edition of the Internation-
erosexuality….What will be the effect of carrying out al Classification of Diseases (ICD-10), replacing it with a di-
such a proposal? No doubt, homosexual activist groups agnosis similar to Ego-Dystonic Homosexuality (Nakajima,
will claim that psychiatry has at last recognized that 2003).
homosexuality is as ‘‘normal’’ as heterosexuality. They
will be wrong. In removing homosexuality per se from
the nomenclature we are only recognizing that by itself Gender Identity Disorder and the DSM
homosexuality does not meet the criteria for being con-
sidered a psychiatric disorder. We will in no way be Today, expressions of gender variance or gender noncon-
aligning ourselves with any particular viewpoint regard- formity are frequently subsumed by the popular term trans-
ing the etiology or desirability of homosexual behavior gender, a term that does not appear in the DSM or any other
(American Psychiatric Association, 1973, pp. 2–3). diagnostic manual.36
Nor did the diagnostic change immediately end psychia- ‘‘Transgender’’ is a relatively new word. It was origi-
try’s pathologizing of some presentations of homosexuality. nally coined by Virginia Prince in the early 1970s to
For in ‘‘homosexuality’s’’ place, the DSM-II contained a new refer to people who lived full-time in a gender that was
diagnosis: Sexual Orientation Disturbance (SOD).34 This not the one that usually went with their genitals (Prince,
33
Retrieved November 9, 2008 from http://www.psych.org/Depart
ments/EDU/Library/APAOfficialDocumentsandRelated/PositionState
ments/197310.aspx.
35
34
Prior to 1980’s DSM-III, APA published a small number of copies of ‘‘As Frank Kameny, a ‘gay activist,’ remarked in 1973, he had no
the DSM. When those were exhausted, another small number was pub- objection to the category of Sexual Orientation Disturbance since any
lished. After running out of copies of DSM-II printed before the 1973 homosexual who was distressed at being homosexual was clearly ‘crazy’
decision, APA printed up new copies in which ‘‘homosexuality’’ was and in need of treatment by a gay counselor to get rid of societally induc-
replaced by ‘‘sexual orientation disturbance’’ (R. L. Spitzer, personal ed homophobia’’ (quoted in Spitzer, 1981, p. 211).
36
communication). Also see Leli and Drescher (2004).
123
436 Arch Sex Behav (2010) 39:427–460
personal communication).37 In the 1990s, the word was Hirschfeld (1923) is credited with being the first person to
taken up by a variety of people who, in their own ways, distinguish the desires of homosexuality (to have partners of
transgressed usual sex and gender expectations. It has the same-sex) from those of transsexualism (to live as the other
now come to have quite a broad meaning. For many sex).38 By the 1920s, physicians in Europe had begun exper-
people, the term transgender includes a wide range of imenting with sex reassignment surgery (SRS).39 However,
sex, gender, and sexual expressions which may include the surgical construction of gender (Garber, 1993) truly seized
heterosexuals, lesbians, gays, bisexuals, queers and the popular imagination when George Jorgensen went to
transsexuals (Devor, 2002, p. 8). Denmark as a natal man and returned to the U.S. in 1952 as
trans woman Christine Jorgensen (Jorgensen, 1967). Amidst
Currah, Green, and Stryker (2008) further elaborate on the
great public and professional controversy, the physicians who
term as
participated in Jorgensen’s SRS published a report of their
… a sense of persistent identification with, and expres- treatment of her in the Journal of the American Medical Asso-
sion of, gender-coded behaviors not typically associ- ciation (Hamburger, Stürup, & Dahl-Iversen, 1953).
ated with one’s sex at birth, and which were reducible The publicity surrounding Jorgensen’s transition, begin-
neither to erotic gratification, nor psychopathological ning with a 1952 New York Daily News headline: ‘‘Ex-GI
paraphilia, nor physiological disorder or malady. The Becomes Blonde Beauty,’’ eventually led to greater popular,
self-applied term was meant to convey the sense that medical, and psychiatric awareness of a scientific concept
one could live non-pathologically in a social gender not that would eventually come to be known as gender identity, as
typically associated with one’s biological sex, as well well as recognition of an increasing number of people wish-
as the sense that a single individual should be free to ing to ‘‘cross over.’’ For those who eventually would come to
combine elements of different gender styles and pre- identify as transsexual, increased public discussions of sex
sentations, or different sex/gender combinations. At one reassignment and gender identity would provide them with a
level, the emergence of the ‘‘transgender’’ category way to put a name to their feelings and desires.40 As a result, a
represented a hair-splitting new addition to the panoply presentation of gender (Stoller, 1985) once considered exceed-
of available minority identity labels; at another level, ingly rare would gradually become more commonplace.41
however, it represented a resistance to medicalization, Yet, at the time of Jorgensen’s 1950s transformation and
to pathologization, and to the many mechanisms whereby for the next three decades, many psychiatrists, and particu-
the administrative state and its associated medico-le- larly psychoanalytic practitioners, remained critical of sex re-
gal-psychiatric institutions sought to contain and deli- assignment as a treatment for gender dysphoric individuals.42
mit the socially disruptive potentials of sex/gender non- Most psychiatric theorizing of that time conflated sexual ori-
normativity. Having an intelligible social identity is the entation and gender identity, and many analysts were unaware
means by which an individual body enters into a pro-
ductive relationship with social power. Thus ‘‘identity
38
politics,’’ the struggle to articulate new categories of It should be noted that there are transgender individuals who desire to
socially viable personhood, remains central to the con- live as a member of the other sex and who neither desire nor seek medical
or surgical treatment to accomplish that goal.
sideration of individual rights in the United States, and 39
In 1930, Lily Elbe (born Einar Mogens Wegener), who had been
to the pursuit of a more just social order. The emergence living as a woman for more than a decade, underwent sex reassignment
of ‘‘transgender’’ falls squarely into the identity politics in surgery in Germany under the supervision of Hirschfeld. Ebershoff
tradition (p. 3). (2000) has written a novel about Elbe, soon to be released as a film. Also
see Hertoft and Sørensen (1978). Hoyer’s (1933) Man Into Woman is
Like homosexuality, medical scrutiny of transgenderism also a classic early account.
40
also began in the 19th century. As noted above, a lack of dis- Blanchard (2003) attributes increased social acceptance of sex
tinction between homosexuality and transgender presen- reassignment to five factors: (1) high-profile, attractive trans pioneers;
(2) positive clinical evidence; (3) the backing of prestigious experts and
tations was common. Krafft-Ebing (1965) weighed in on the institutions; (4) sympathetic media; and (5) a favorable social climate.
side of transgenderism as psychopathology, documenting 41
In line with these cultural changes, in recent years a few states have
both cases of gender dysphoria and of gender variant indi- enacted laws that establish ‘‘gender identity’’ as a protected legislative
viduals born to one sex yet living as members of the other. characteristic, although it remains to be defined as a ‘‘suspect category,’’
a term for groups likely to be subject to discrimination (other suspect
classifications include race, ethnicity, age, sex, and, less frequently,
37
Prince’s original term was ‘‘transgenderal’’ and she coined it as an sexual orientation). This is a remarkably rapid cultural shift as the mod-
alternative to ‘‘transsexual’’ to describe people who lived in the non- ern coinage of ‘‘gender identity’’ only emerged in the mainstream scien-
natal gender but did not have transsexual surgery. Prince’s life story and tific community half a century ago (Stoller, 1964).
42
a collection of some of her academic publications can be found in Prince, See Socarides (1969), Hertoft and Sørensen (1978), and McHugh
Ekins, and King (2005). Prince passed away on May 2, 2009 at the age of (1992) for psychiatric views opposing sex reassignment and Chiland
96. (2000, 2003) for a contemporary, psychoanalytic criticism of SRS.
123
Arch Sex Behav (2010) 39:427–460 437
of, indifferent to, or at times hostile towards research from non- newly revamped DSM-III would abandon the psychodynamic
analytic sources that did not support their own theories (Bayer, theories informing the first two volumes and instead adopt a
1981; Lewes, 1988). Many physicians and psychiatrists criti- neo-Kraepelian, descriptive, symptom-based framework draw-
cized using surgery and hormones to irreversibly—and in their ing upon contemporary research findings (Spiegel, 2005; Zuc-
view incorrectly—treat people suffering from what they per- ker & Spitzer, 2005). In that shift, a growing body of research on
ceived to be either a severe neurotic or psychotic, delusion- child and adult gender identity found its way into the manual.
al condition in need of psychotherapy and ‘‘reality testing.’’ Zucker and Spitzer (2005) summarize the vicissitudes of the
Mainstream medical thinking at the time was captured in a current gender diagnoses from DSM-III through DSM-IV-TR:
1960s survey of 400 physicians that included psychiatrists,
In the third edition of the Diagnostic and Statistical
urologists, gynecologists, and general medical practitioners
Manual of Mental Disorders (DSM-III; APA, 1980), there
asked to give their professional opinions about a case history of
appeared for the first time two psychiatric diagnoses per-
a trans individual seeking SRS.43 Green (1969) summarized
taining to gender dysphoria in children, adolescents, and
the findings as follows:
adults: gender identity disorder of childhood (GIDC) and
Eight percent [8%] of the respondents considered the transsexualism (the latter was to be used for adolescents
transsexual ‘‘severely neurotic’’ and fifteen percent [15%] and adults). In the DSM-III-R (APA, 1987), a third diag-
considered the person ‘‘psychotic.’’ The majority of the nosis was added: gender identity disorder of adolescence
responding physicians were opposed to the transsex- and adulthood, nontranssexual type. In DSM-IV (APA,
ual’s request for sex reassignment even when the pa- 1994, 2000a), this last diagnosis was eliminated (‘‘suns-
tient was judged nonpsychotic by a psychiatrist, had etted’’), and the diagnoses of GIDC and transsexualism
undergone two years of psychotherapy, had convinced were collapsed into one overarching diagnosis, gender id-
the treating psychiatrist of the indications for surgery, entity disorder (GID), with different criteria sets for child-
and would probably commit suicide if denied sex reas- ren versus adolescents and adults. (p. 32)
signment. Physicians were opposed to the procedure
The decision to place transsexualism in the DSM was based
because of legal, professional, and moral and/or reli-
on the research and clinical contributions of John Money, Harry
gious reasons. In contrast to the conservatism with which
Benjamin, Robert Stoller, and Richard Green. All took issue
granting of sex-reassignment procedures was viewed,
with the prevailing psychiatric view of their time that dismissed
there was a paradoxical liberalism in the approach to
the existence of transgender subjectivities as a unique psycho-
these patients should they already have been successful
logical phenomenon in its own right. The pioneering activities
in obtaining their surgery elsewhere. Among the
of these men—creating gender clinics and providing medical
respondents, three quarters [75%] were willing to allow
and surgical treatment to trans individuals—ultimately led to
the postoperative patient to change legal papers such as
the new diagnosis in the DSM. They also changed professional
a birth certificate and to marry in the new gender, and
and eventually public attitudes toward sex reassignment. Their
one-half [50%] would allow the person t adopt a child as
contributions are briefly summarized below.
a parent in the new gender. (pp. 241–242)
John Money, a psychologist and sexologist, first began pub-
It was in this cultural context that the first two editions of lishing his theories regarding gender identity development in the
the DSM were published. With a significant emphasis on psy- 1950s (Money et al., 1955a, 1955b, 1957). Based on studies of
choanalytic theories of normal and pathological mental func- children born with intersex conditions, Money theorized that
tioning, the GID diagnoses or anything equivalent did not one’s sense of being male or female—what eventually came to
appear in either one (APA, 1952, 1968). By 1980, however, a be known as one’s gender identity—was acquired and that ac-
quisition was primarily determined by external, environmental
factors. Citing cases of gender assignment in intersex children
born with ambiguous genitalia, Money believed parental atti-
43
‘‘The case history in the questionnaire read as follows: Since early tudes have a strong effect on whether a child accepts the gender
childhood, this 30-year-old biological male has been very effeminate in category to which it had been surgically and medically assigned.
his mannerisms, interests, and daydreams. His sexual desires have al- For Money, the role of the psychosocial environment was crit-
ways been directed toward other males. He would like to be able to dress
ical: ‘‘In those instances [where the child does not accept the
exclusively in woman’s clothes. This person feels inwardly and insists to
the world that he is a female trapped in a male body. He is convinced that category to which it has been assigned,]… it is common to find a
he can only be happy if he is operated on to make his body look like that history in which uncertainty as to the sex of the baby at birth was
of a woman. Specifically, he requests the removal of both testes, his transmitted to the parents and never adequately resolved [within
penis, and the creation of an artificial vagina (all of which can, in fact, be
the parents’ mind]’’ (Money & Ehrhardt, 1996, p. 153).
done surgically). He also requests that his breasts be made to appear like
a woman’s, either surgically or by the use of hormones (this, too, is Money coined the term gender role (Money 1985a, 1994),
medically possible)’’ (Green, 1969, p. 236). which he defined as those things that a person says or does to
123
438 Arch Sex Behav (2010) 39:427–460
disclose himself or herself as having the status of boy or man, 2008; Pfäfflin, 1997).46 Benjamin was a pioneering maverick
girl or woman, respectively (e.g., general mannerisms, deport- who offered transgender individuals hormonal treatment at a
ment and demeanor, etc.) and regardless of the person’s ana- time when mainstream psychiatry and medicine regarded gen-
tomical sex. Gender identity refers to one’s persistent inner der incongruent individuals as confused homosexuals, neu-
sense of belonging to either the male or female gender category. rotics, transvestites, schizophrenic or some combination thereof
Money (1994) credits the latter term’s coinage to Robert Stol- (e.g., Socarides, 1969). Benjamin, who had an essentialist
ler.44 Gender identity can be an independent variable in relation view of transsexualism, had little regard for his era’s psy-
to sexual orientation. For example, some people can be born chiatrists or psychoanalysts (Ihlenfeld, 2004). He ‘‘believed
with a male body, have a female gender identity, and, in some that the transsexual suffers from a biological disorder, that his
cases, be attracted to men (androphilic) while others may be brain was probably ‘feminized’ in utero. He eschews any psy-
attracted to women (gynephilic). Money came to see gender chological explanation’’ (Person, 2008, p. 272). Consistent
identity as the private experience of gender role and gender role with his essentialist view, he believed psychotherapeutic
as the public manifestation of gender identity: ‘‘As originally attempts to change gender identity were ‘‘futile’’ (Benjamin,
defined, gender role consists of both introspective and the ex- 1966, p. 28). As an outgrowth of his interests in the devel-
traspective manifestations of the concept. In general usage, the oping fields of endocrinology, gerontology, and sexology in
introspective manifestations soon became separately known as the 1920s and 1930s, Benjamin was among the first physi-
gender identity. The acronym, G-I/R, being singular, restores cians to experiment with hormonal and surgical treatments
the unity of the concept’’ (Money, 1985b, p. 279; see also Money for aging—he eventually pioneered the treatment of gender
& Ehrhardt, 1996). dysphoric individuals using sex hormones (Ihlenfeld, 2004).
Money believed a person’s gender identity was fixed by three According to a colleague, ‘‘By 1972, Benjamin had diag-
years of age, and considered efforts to change a person’s gender nosed, treated, and befriended at least a thousand of the ten
identity difficult, if not impossible, in anyone older. Pessimism thousand Americans known to be transsexual. In the process,
about changing an adult’s gender identity left only one thera- he had come to be regarded not only as the discoverer but also
peutic alternative to improve the affected individual’s well- as the patron saint of transsexuals’’ (Person, 2008, p. 260).
being: sex reassignment. In the mid-1960s, in the wake of Notably, he accomplished this in a private practice setting
Money’s theoretical work and his clinical and research findings, without either university or academic support. In acknowl-
Johns Hopkins opened the first university-affiliated, multidis- edgment of Benjamin’s early advocacy for the medical treat-
ciplinary gender clinic offering sex reassignment to transsexuals ment of transsexualism, in 1979 the newly formed Harry Ben-
seeking treatment (Green & Money, 1969). More than 40 aca- jamin International Gender Dysphoria Association (HBIG-
demic centers in the U.S. would later open gender clinics as well DA),47 which would go on to develop standards of care (SOC)
(Denny, 1992, 2002).45 for treating trans individuals, was named in his honor.48
Harry Benjamin, a physician, is credited with both popu- Robert Stoller was a preeminent member of both the
larizing the term transsexual in its current usage and for raising American psychiatric and psychoanalytic establishments of his
awareness about trans individuals within the medical profes- time (Green, 2009a). Like Money, Stoller’s (1968) theorizing
sion (Benjamin, 1966; Green, 2009a; Ihlenfeld, 2004; Person, about gender evolved from working with both intersex and
transsexual patients. Stoller (1964) is credited with introducing
the concept of gender identity into both the psychoanalytic lit-
44 erature and into the consciousness of many psychiatrists as
‘‘I trace my initial acquaintance with this new term to communica-
tion at the time with Evelyn Hooker, the psychologist now famed for
her pioneering studies in Los Angeles that led to the official depathol-
ogization of homosexuality. According to a personal communication
(1984) with the late Robert Stoller, there was a psychoanalytic gender 46
identity study group at the University of California at Los Angeles Hirschfeld (1923) is credited with coining the term transvestism in
(UCLA) Medical Center during this same period, the middle 1960s’’ 1910 and transsexualism in 1923, although he did not define the latter in
(Money, 1994, p. 166). Regular attendees of that study group included its current usage (Pfäfflin, 1997). Cauldwell (1949) is often credited with
Ralph Greenson, Judd Marmor, Robert Stoller, and Richard Green (R. the first usage of the contemporary meaning of transsexualism (Hertoft
Green, personal communication, July 6, 2009). & Sørensen, 1978; Pfäfflin, 1997).
47
45
Money, as well as his ‘‘nurture’’ theory of gender identity develop- Founding members include Jack Berger, Richard Green, Donald
ment, was attacked in Colapinto’s (2000) As Nature Made Him. He was Laub, Walter Meyer, Jude Patton, Charles Reynolds, Jr., Paul Walker,
accused, among other things, of falsifying published data about a pair of Alice Webb, and Leo Wollman. Retrieved from A. H. Devor’s web
twin boys, one of whom lost his penis at age 8 months in a botched based history, ‘‘Reed Erickson and The Erickson Educational Foun-
circumcision and was later reassigned to be a girl. Money claimed the dation,’’ at http://web.uvic.ca/*erick123/#HB, July 7, 2009.
48
child, referred to as ‘‘John/Joan’’ in the case report, successfully accept- In 2006, it was proposed that HBIGDA’s name be changed to the
ed gender reassignment. In Colapinto’s book, John/Joan was revealed World Professional Association for Transgender Health (WPATH).
to be David Reimer who publicly came forward to tell his story of having That name change became official in 2009 after a membership ballot
rejected female assignment. (H. F. L. Meyer-Bahlburg, personal communication, March 2009).
123
Arch Sex Behav (2010) 39:427–460 439
well.49 However, in contrast to Benjamin’s essentialist views, entity and a great deal of empirical research that exam-
Stoller (1967) believed that in some cases, childhood family ined its phenomenology, natural history, psychologic
dynamics were responsible for ‘‘causing’’ adult transsexual- and biologic correlates, and so forth. Thus, by the time
ism.50 Stoller (1985), undoubtedly influenced by the separation- DSM-III was in its planning phase in the mid-1970s,
individuation theories of Mahler, Pine, and Bergman (1975), there were sufficient clinical data available to describe
opined that GID in boys was a ‘‘developmental arrest… in the phenomenon, to propose diagnostic criteria, and so
which an excessively close and gratifying mother–infant sym- on (Zucker & Spitzer, 2005, p. 37).
biosis, undisturbed by father’s presence, prevents a boy from
According to Zucker and Spitzer, the case for including GID
adequately separating himself from his mother’s female body
of Childhood in the DSM-III was made for similar reasons:
and feminine behavior’’ (p. 25).
As a medical student at Johns Hopkins, Richard Green At the same time, there also was an emerging clinical and
studied cross-gender behavior in children under the supervision research literature on children who expressed the desire
of his mentor John Money. Green did his psychiatric training as to be of the opposite sex, leading to a similar situation,
a UCLA resident with Robert Stoller, and later developed a that is, there was a clear description of the phenomeno-
close relationship with Harry Benjamin (Green, 1987, 2009a). logy, development of diagnostic criteria, and so on (e.g.,
Green and Money (1969) co-edited a groundbreaking, multidis- Green, 1974; Stoller, 1968, 1975). Although research on
ciplinary treatment textbook, Transsexualism and Sex Reas- both GIDC and transsexualism likely lagged behind
signment, and published two early and important scholarly other psychiatric phenomena with much higher preva-
works in the field of GIDC research (Green & Money, 1960, lence rates, expert consensus clearly concluded that
1961). His later volume, The ‘‘Sissy Boy Syndrome’’ and the there was sufficient indication of clinical usefulness and
Development of Homosexuality (Green, 1987) was a prospec- acceptability for these two disorders to be considered for
tive study that tracked into adulthood the development of 66 the DSM-III. In this respect, the reliance on expert
gender-atypical boys who stated a wish to be a girl. Seventy-five consensus regarding parameters that justified inclusion
percent of the children Green studied grew up to be gay men. was probably not much different from the many other
Stoller and Green were among the most prominent of psy- DSM diagnoses, such as borderline personality disorder
chiatrists who supported the APA decision to remove homo- or narcissistic personality disorder, that had not been
sexuality from the DSM-II (Stoller et al., 1973). They also subjected to more systematic field trials (Zucker &
served on the DSM-III Subcommittee on Psychosexual Disor- Spitzer, 2005, p. 37).
ders that recommended including transsexualism (now called
The World Health Organization (1992) followed the
GID in adolescents and adults) in the DSM-III.
DSM-III’s lead in 1992’s ICD-10 and included the diagnoses
During the 1960s, North American psychiatry had begun of transsexualism and gender identity disorder of childhood.
to take a look at the phenomenon of transsexualism in It should be noted that while the two GID diagnoses are
adults (see, for example, Green & Money, 1969; Stoller, grouped together in DSM, treatment approaches for GIDC seem
1968). It became apparent that psychiatrists and other at marked variance from the treatment philosophy of GID in
mental-health professionals had become increasingly adolescents and adults. In the latter case, successful treatment of
aware of the phenomenon, that is, of adult patients report- gender dysphoria through sexual reassignment seems relatively
ing substantial distress about their gender identity and uncontroversial.51 However, there is much controversy about
seeking treatment for it, typically hormonal and surgical the treatment of GIDC. Until recently, in cases of GIDC in very
sex-reassignment. Indeed, there were enough observed young children, treating gender dysphoria to prevent transition
cases that it was possible in the 1960s to establish the first in later life was felt to be a legitimate goal. Only when such
university- and hospital-based gender identity clinics for efforts fail would transition be sanctioned (Wallien & Cohen-
adults. Many clinicians and researchers were writing Kettenis, 2008; Zucker, 2008a, 2008b).
about transsexualism, and by 1980, there was a large It is beyond the scope of this paper to review all the issues in
enough database to support its uniqueness as a clinical the debates regarding appropriate treatment of gender variant
children. It should be noted, however, that changing cultural
49
A search of the largest psychoanalytic data base, PEP-WEB (http:// attitudes about what exactly constitutes ‘‘appropriate’’ expres-
www.pep-web.org/), shows that the term ‘‘gender identity’’ only ap- sions of gender are leading some clinicians to encourage par-
pears in the psychoanalytic literature for the first time in the 1964 Stoller
paper.
ents in helping their children transition at earlier ages (Ken-
50
Stoller’s hypothesis of a ‘‘blissful symbiosis’’ between mother and nedy, 2008; Rosin, 2008; Spiegel, 2008a, 2008b). Further-
son as a ‘‘cause’’ of GID is disputed by Coates (1990, 1992; Coates & more, as in the case of homosexuality in the 1970s, LGBT
Wolfe, 1995), who argues for some combination of inborn, biological
51
temperament and alternative family dynamics as factors predisposing to However, see Chiland (2003), Hertoft and Sørensen (1978), and
GID of childhood. McHugh (1992) for critical views of SRS.
123
440 Arch Sex Behav (2010) 39:427–460
advocacy groups have had some recent successes in changing nor idolaters, nor adulterers, nor effeminate, nor abusers
professional opinions about GID diagnoses. For example, in of themselves with mankind, nor thieves, nor covetous,
November 2008, ‘‘After repeated contacts’’ from the Swedish nor drunkards, nor revilers, nor extortioners, shall inherit
Association for Sexuality Education (RFSU) and the Swed the kingdom of God. (I Corinthians 6:9).53
ish Federation for Lesbian, Gay, Bisexual and Transgen
In addition to condemning sexual transgressions, some
der Rights (RFSL), the Swedish National Board of Health and
biblical passages touch upon what would today be referred to
Welfare (Transvestitism no longer, 2008), a governmental
as transvestism and transsexualism. For example, Deuter-
agency made Sweden the first country to remove the GIDC
onomy 22:5 explicitly forbids cross-dressing: ‘‘The apparel
diagnosis from the Swedish version of the ICD-10, citing its
of a man shall not be upon a woman and a man shall not wear
potential, along with five other diagnoses, of being offensive
woman’s garments for anyone who does these is an abomi-
and contributing to prejudice.52 The Swedish diagnostic man-
nation to the Lord.’’ In orthodox Jewish traditions, Leviticus
ual, however, will retain the Transsexualism diagnosis in or-
22:24, ‘‘And one that is bruised, or crushed, or broken, or cut
der to continued providing sex reassignment.
in the testicles, shall ye not offer unto the Lord; and in your
land shall ye not make the like,’’ is interpreted as a prohibition
against castrating both animals and human beings and is ta-
Homosexuality and GID: Parallels
ken to forbid sex reassignment surgery.54
For centuries, religious views and the legal consequences
Many trans activists, with the support of LGB and straight
of those prohibitions held sway.55 However, accompanying
allies, are calling for removal of the GID diagnoses. In many
the rise of Western secularism, in the mid-19th century,
respects, these calls resemble historic arguments that led to
scientific and medical explanatory models of nature sought
the 1973 removal of homosexuality from the DSM-II.
to supplant religious and supernatural explanations. Yet, ‘‘as
ecclesiastical authority began to wane with the rise of the
The Parallel of Turning Sin into Illness
modern state, the religious abhorrence of homosexual prac-
tices was carried over into secular law’’ (Bayer, 1981, p. 17).
Traditionally, religion has played a strong role in codifying
In the process of casting a critical, scientific eye on a range of
socially acceptable expressions of gender and sexuality. Gender
what were then deemed to be socially unacceptable behaviors,
beliefs about the proper roles of men and women are firmly
many ‘‘sins’’ would eventually come to be classified as ‘‘ill-
rooted in Judeo-Christian and other traditions that regard gender
nesses’’: demonic possession redefined as insanity, drunkenness
role transgressions as grounds for censure and castigation—
as alcoholism, and sodomy as an illness called homosexuality.
even punishment by death. Given the historical conflation of
Bayer (1981) contends that this was a model ‘‘inspired by the
gender expression and sexual orientation, biblical prohibitions
vision of a thoroughly deterministic science of human action.
against homosexuality are, at times, framed in language that
It rejected the ‘pre-modern’ stress on will and the concomi
describes men as transgressing their ‘‘natural’’ (that is, God-
tant moral categories of right and wrong. Instead it sought the
given) gender roles:
causes of deviance in forces beyond the control of the individ-
• Thou shalt not lie with mankind, as with womankind: it is ual’’ (p. 18).
abomination. (Leviticus 18:22) Yet, by the mid-20th century, critics of psychiatry and the
• If a man also lie with mankind, as he lieth with a woman, medical profession would argue that psychiatric disorders
both of them have committed an abomination: they shall merely reflected existing social attitudes and prejudices and
surely be put to death; their blood shall be upon them. that they were often nothing more than forms of social control.
(Leviticus 20:13)
• And likewise also the men, leaving the natural use of the
woman, burned in their lust one toward another; men with 53
Other biblical passages interpreted as prohibitions against homo-
men working that which is unseemly, and receiving in sexuality can be found in Genesis 19, Leviticus 18:7, Judges 19, I Kings
themselves that recompence of their error which was 22:46, II Kings 23:7, and I Timothy 1:9–10.
meet. (Romans 1:27) 54
Thanks to Naomi Mark for the Biblical references as well as the
• Know ye not that the unrighteous shall not inherit the information regarding their current interpretations within the orthodox
kingdom of God? Be not deceived: neither fornicators, Jewish community.
55
Boswell (1980, 1994) challenges the historical view of a linear
tradition of condemnation, arguing that in different historical eras the
52
The other five diagnoses are F64.1, Dual-role transvestism; F65.0, western church tolerated same-sex relationships. Boswell (1980) and
Fetishism; F65.1, Fetishistic transvestism; F65.6, Sadomasochism, and Gomes (1996) point out the selective use of biblical prohibitions by reli-
F65.6, Multiple disorders of sexual preference. See ‘‘Transvestism ‘no gious authority figures. Gomes (1996) and Helminiak (1994) offer alter-
longer a disease’ in Sweden,’’ published November 17, 2008; retrieved native religious interpretations of traditional religious dogma condemn-
from http://www.thelocal.se/15728/20081117/, February 15, 2009. ing homosexuality.
123
Arch Sex Behav (2010) 39:427–460 441
The most telling example of medicine’s history of diagnostic homophile movement56 as its members and allies openly
excess—and one easily held up for ridicule—is drapetomania, debated the relative social merits and costs of pathologizing
a 19th century ‘‘disorder of slaves who have a tendency to run homosexuality. For example, Cory57 (1965) spoke not only
away from their owner due to an inborn propensity for wan- for retaining the medical model but also defended the mental
derlust’’ (Schwartz, 1998, p. 357). Szasz (1960), a psychiatrist, health professionals coming under attack from an increas-
psychoanalyst, and spokesperson for a nascent anti-psychiatry ingly militant homophile movement:
movement, declared mental illnesses to be myths, no more
Once the name was Edmund Bergler [1956]; today it is
than metaphors for physical illness. He characterized psychi-
Albert Ellis… I am more and more convinced that the
atric nomenclature as an effort by mental health practitioners
homophile movement in the United States… will do
to exercise control in the guise of ‘‘providing treatment’’ for
great harm to its struggle if it gets into a head-on clash
individuals by first defining them as ‘‘patients’’ and then
with men of science whose work it finds threatening:
labeling their thoughts, feelings, and behaviors as ‘‘symp-
and that there is nothing inconsistent between accep-
toms’’ of imaginary ‘‘diseases.’’ For Szasz (1965, 1974a), psy-
tance of the work of psychotherapists who report suc-
chiatry’s diagnosis of homosexuality was a prototypical ex-
cess, nay cure, and the struggle for the right to par-
ample of social control as was the medical model of drug
ticipate in the joys of life for those who cannot, will not
addiction and the concomitant criminalization of drug users.
or do not undergo such change (pp. 8–9).
Although few psychiatrists today would accept Szasz’s
line of reasoning, particularly his theory of schizophrenia By the mid-1960s, Cory’s approach—advocating for gay
(Szasz, 1974b), his arguments regarding the social context people to have access to treatment of their homosexuality and
of diagnosing mental disorders are not completely without for the gay community to collaborate with psychiatrists who
merit. For example, the first edition of the DSM (APA, 1952) pathologized homosexuality—was rejected by American
explicitly and non-self consciously articulated a role for homophile groups. Following the 1969 Stonewall riots, the
social values in making a diagnosis of the overarching cate- ‘‘homophile movement’’ evolved into ‘‘gay liberation’’ and
gory of sociopathic personality disturbances which included repudiated the medical model of homosexuality. The rest, as
homosexuality: ‘‘Individuals to be placed in this category are they say, is history.
ill primarily in terms of society and conformity with the Undoubtedly trans individuals in 1980, seeing a psychi-
prevailing cultural milieu, and not only in terms of personal atric diagnosis as the key to obtaining medical and surgical
discomfort and relations with other individuals’’ (p. 38, my treatment, did not criticize Transsexualism’s inclusion in the
emphasis). DSM-III. However, since treatment for gender incongruent
While physicians and psychiatrists are often accused of children focused on preventing adult transsexualism, and in
seeking power and control, there are also altruistic reasons for the case of some clinicians who claimed they were preventing
turning ‘‘sinners’’ into ‘‘patients’’: the medical model’s promise homosexuality and cross-dressing (Rekers, Bentler, Rosen,
of hope for treatment and cure. An ill person was not necessarily & Lovaas, 1977), GIDC received a much chillier reception.
responsible for his or her ‘‘symptoms,’’ and, in the best of cir- Some activists and academics in the field of queer theory
cumstances, would benefit from therapeutic compassion rather (Mass, 1990b; Sedgwick, 1991) asserted that the new diag-
than religious judgment and condemnation. nosis was a ruse perpetrated by psychiatrists to prevent homo-
The stigma of psychiatric illness and the paternalism of sexuality in adults.58 Zucker and Spitzer (2005) refuted that
medical practitioners notwithstanding, many ‘‘homosexuals’’ interpretation of historical events on the basis of three rea-
accepted, if not embraced, the medical model as an alternative sons: (1) there was no need for a veiled backdoor diagnosis to
to religious and legal condemnation. While some saw in the prevent homosexuality because DSM-III [still] contained the
illness model hopes for a ‘‘cure,’’ Bayer (1981) sees a more diagnosis of ego-dystonic homosexuality; (2) that EDH was
practical concern: itself eventually removed from the DSM-III-R because of a
lack of any empirical basis to support the diagnosis; and (3)
Since the threat of criminal prosecution was the im-
‘‘several clinicians and scientists who argued in favor of
mediate danger, it is not surprising that homosexuals
delisting homosexuality from the DSM-II were members of
did not attack the standard psychiatric view of sexual
deviation. With professional support hard to come by, it 56
The most notable organizations in this movement were the Matta-
would have been surprising if those attempting to foster chine Society for men and the Daughters of Bilitis for women. The
legal reform had diverted energy to the attack of those Mattachine Review and DOB’s The Ladder would publish numerous
who argued that homosexuality was an inappropriate articles debating normalizing versus pathologizing models.
57
target of the criminal law (pp. 67–68). Donald Webster Cory was the pseudonym of Edward Sagarin.
58
To the present day, this argument continues to resurface in the
By the 1950s and 1960s, ambivalence toward the medical writings of gay academics and clinicians (Ault & Brzuzy, 2009; Bryant,
model would play out in the publications of the American 2007; Corbett, 1996; Haldeman, 2000).
123
442 Arch Sex Behav (2010) 39:427–460
the DSM-III subcommittee on psychosexual disorders that by society and by the families was essential’’ (p. 151, my
recommended the inclusion of the GIDC diagnosis in DSM- emphasis). Similarly, the gender clinics at Johns Hopkins and
III’’ (p. 35). other academic centers supported a treatment model of assimi-
Why would the same experts who persuasively and success- lation into cisgender culture. However, by the 1980s:
fully argued for removal of homosexuality from the DSM-II59
The closing of [most] U.S. gender clinics created a treat-
advocate for including the GID diagnoses in the DSM-III? As
ment vacuum which resulted in the slow development
the following history reveals, what seems paradoxical today is
of a market economy for the treatment of transsexual-
the result of decisions made by individuals who lived in a dif-
ism. Free from the restrictive policies of the gender pro-
ferent time with different ideas, different social values regard-
grams, transsexuals began to orchestrate their own sex
ing gender, and different clinical and social agendas.
reassignments, choosing services and service providers
In the 1970s, professional advocates of the medical model of
in an a la carte fashion. Long kept out of communica-
transsexualism found themselves arguing against a common
tion with one another by privacy requirements of gen-
psychiatric belief that saw trans people as severely mentally
der clinics and by the insistence of the clinics that to be
disturbed. Using an alternative medical model of illness, albeit
‘‘proper’’ transsexuals they must blend into society and
one less pathologizing than the theories of neurosis and psy-
disappear, transsexuals began communicating with one
chosis they opposed, they expanded professional awareness and
another, seeking and providing information and com-
knowledge about gender identity and sex reassignment and
paring notes… By 1985, there were a number of support
were eventually successful in changing psychiatric and medical
groups and regional conferences which welcomed both
opinions regarding the authenticity of trans subjectivities. As
crossdressers and transsexuals. Around 1990, trans-
a result, they created increased possibilities for anatomically
sexuals, who had been conspicuously absent from the
dysphoric transgender individuals to obtain the treatment they
literature, began to publish, adding their voices to those
needed to live their lives unnoticed and unmolested as members
of feminist scholars… (Denny, 2002, p. 40).60
of the other sex. Yet ironically, partially as a result of changes
they helped bring about (authenticating and, through the DSM One consequence of less medical control of postoperative
and later the ICD-10, solidifying a medical category of indi- living and an increased contact among individuals were new-
vidual known as the ‘‘transsexual’’) and partially due to cir- ly formed trans communities that proposed a:
cumstances beyond their control (the closing of university-
new [alternative] transgender model, [in which] trans-
affiliated gender clinics following the publication of Meyer and
sexuals were not mentally ill men and women whose
Reter’s (1979) controversial follow-up study claiming SRS
misery could be alleviated only by sex reassignment,
confers no objective advantage in terms of social rehabilitation),
but rather [they were] emotionally healthy individuals
cultural attitudes about gender would also change, perhaps in
whose expression of gender was not constrained by
ways these medical pioneers never envisioned.
societal expectations. Instead, the pathology was shif-
For example, the early transsexualism medical literature
ted from the gender-nonconformist to a society which
gives little indication of professional encouragement to live
cannot tolerate difference… Many transsexuals, how-
one’s post-transition life as an openly trans person. Christine
ever, have reinterpreted their experience in the light of
Jorgensen, who did come out as an openly trans woman, was a
the transgender model and are less likely to disappear
rare exception. Instead, early professional proponents of sex
into society after sex reassignment than was the case
reassignment seemed more likely to endorse (at least in their
under the medical model (Denny, 2002, pp. 43–44).
published writings) postoperative assimilation, which meant
living unobtrusively as a member of the other sex. Benjamin As increasing numbers of trans individuals began to come
(1966), for example, in discussing the results of male-to-fe- out of their closets, the gay liberation movement once again
male sex reassignment, noted that ‘‘several factors have to be evolved and expanded more broadly into advocacy for les-
considered: the physical and mental health, the emotional bian, gay, bisexual, and transgender (LGBT) civil rights.
state, the social status, as compared to that before the change; Sexual orientation and transgender identities, once conflated,
the attitude of the family, the position in society, and last but by and only recently separated from each other as discrete cat-
no means least, the sex life, largely dependent upon the ade- egories, now found common political cause. One historical
quacy of the newly created female genitals, especially the fact supporting such a political alliance was that many of the
vagina’’ (p. 150). For an end result ‘‘to be assessed good, the protestors at the 1969 Stonewall riots were transgender
total life situation had to be successful as well as the sex life. A
good integration into the world of women with acceptance
59 60
See, for example, Green (1972), Stoller (1973), and Stoller et al. Among the 1990s authors who self-identified as trans are Feinberg
(1973). (1993), Bornstein (1994), and Wilchins (1997).
123
Arch Sex Behav (2010) 39:427–460 443
(Duberman, 1994; Stryker, 2007).61 There was also a very From Medical Illness to Civil Rights Movements
practical reason for the embrace of trans inclusion: those who
oppose gay rights ‘‘see lesbian, gay, bisexual, and queer At the time of the 1973 APA decision, organized psychiatry
people’s interests as being almost the same, if not identical, to was not yet prepared to call homosexuality a normal variant
those of trans people’’ (Devor, 2002, p. 6).62 Trans inclusion of human sexuality. However, the diagnostic revision did end
would accelerate in the 1990s, as many national LGB advo- organized medicine’s formal participation in the social stig-
cacy organizations amended their mission statements to in- matization of homosexuality. The APA decision shifted de-
clude gender identity and transgender people.63 bate about homosexuality into the moral and political realms
by depriving religious, governmental, military, media, and
It started happening in the mid-1990s, in response to the
educational institutions of medical or scientific rationaliza-
queer movement of the early 1990s, and in response to a
tion for discrimination.
decade of radical AIDS activism. Fighting to end the
With psychiatry no longer officially participating in stig-
epidemic required, from a public health point of view,
matization, a historically unprecedented social acceptance of
getting past the squabbles of homosexual identity pol-
gay men and women gradually ensued. Whether the APA role
itics left over from the 1960s, ‘70s and ‘80s. The Re-
was causal, as this author has asserted (Drescher, 2006c) or a
aganite right wanted to label AIDS ‘‘gay-related immune
bellwether of wider social changes, is open to debate. Never-
deficiency’’ even though viruses are no respecters of
theless, those who accepted scientific authority on such mat-
identity. AIDS was not a gay disease, but convincing
ters gradually came to accept the APA position and a new
others of that fact required a transformation of sexual
cultural perspective emerged: (1) if homosexuality is not an
politics. It fostered political alliances between lots of
illness, and (2) if one does not literally accept biblical prohi-
different kinds of people who all shared the common
bitions against homosexuality, and (3) if contemporary, sec-
goal of ending the epidemic–and sometimes precious
ular democracy separates church and state, and (4) if openly
little else (Stryker, 2007).
gay people are able and prepared to function as productive
Because the transgender community is so much smaller citizens, then what is wrong with being gay? And if there is
than the lesbian, gay, and bisexual one, members of the for- nothing wrong with being gay, then what moral and legal
mer have successfully increased their cultural and political principles should the larger society endorse in helping gay
clout by aligning with the latter as an ostensibly united LGBT people openly live their lives (Drescher, 2002c, 2006b)?
community. Trans advocacy today encompasses civil rights, There has been ample consideration of these questions in the
access to care, and promoting greater tolerance of gender last four decades and consequently much has changed. In 1973,
variance not just in trans individuals, but also in society in ‘‘homosexual behavior’’ was illegal in most of the 50 United
general (Drescher, 2002e; Wilchins, 1997). States. The 1970s began the proliferation of local and eventually
state civil rights ordinances making discrimination on the basis
of sexual orientation illegal.64 As acceptance of gay people in-
61
Stryker (2007) further notes, ‘‘Transgender people have their own creased, by 2003, three quarters of the states had repealed their
history of civil rights activism in the United States, one that is in fact sodomy laws. Then, on June 26, 2003, the U.S. Supreme Court
older, though smaller and less consequential, than the gay civil rights made a 6-3 historic ruling in Lawrence and Garner v Texas to
movement. In 1895, a group of self-described ‘‘androgynes’’ in New
overturn the country’s remaining sodomy laws. National and
York organized a ‘‘little club’’ called the Cercle Hermaphroditos, based
on their self-perceived need ‘‘to unite for defense against the world’s state governments are increasingly addressing the rights of same-
bitter persecution.’’ Half a century later, at the same time some gay and sex couples to adopt and to act as foster parents to children.
lesbian people were forming the Mattachine Society and the Daughters Even some religious organizations have changed their views
of Bilitis, transgender people were forming the Society for Equality in
on homosexuality. In 2005, United Church of Christ became the
Dress. When gay and lesbian people were fighting for social justice in the
militant heyday of the 1960s, transgender people were conducting sit-in first mainline Christian denomination to support same-sex mar-
protests at Dewey’s lunch counter in Philadelphia, fighting in the streets riage. Major religious groups that permit same-sex unions but
with cops from hell outside Compton’s Cafeteria in San Francisco’s that do not give them the same status as marriage include the
Tenderloin, and mixing it up at Stonewall along with lots of other folks.’’
62
Episcopal Church, the Evangelical Lutheran Church, and Re-
Devor made these comments in a paper based on a lecture to members
form Judaism. Reform Judaism now trains openly gay and les-
of the Association of Gay and Lesbian Psychiatrists (AGLP). Following
a series of discussions leading to publications in its Journal of Gay and bian rabbis.
Lesbian Psychotherapy, in 2001 AGLP amended its bylaws with gender
identity and transgender inclusive language (see Devor, 2002; Denny,
2002; Drescher, 2002b; Seil, 2002). 64
A notable exception is the U.S. federal government which to date
63
Devor (2002) cites examples of trans inclusion at the National Gay does not yet offer any protection against discrimination on the basis of
and Lesbian Task Force (NGLTF) in 1997, Parents, Families and either sexual orientation or gender identity. In 1990 the federal govern-
Friends of Gays (PFLAG) in 1998, and the Human Rights Campaign ment passed the Hate Crimes Statistics Act, the first time a federal statute
(HRC) in 2001. recognized sexual orientation (Schmalz, 1992).
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444 Arch Sex Behav (2010) 39:427–460
Most telling in the movement for normalization has been the Parallels in Arguments for Diagnostic Removal
rapidly changing landscape of same-sex marriage. At the time of
this writing, marriage equality can be found in Belgium, Can- These civil rights advances notwithstanding, many in the
ada, the Netherlands, Norway, South Africa, Spain, Sweden, LGBT movement are critical of psychiatry’s GID diagnoses.
and six U.S. states: Connecticut, Iowa, Maine, Massachusetts, Like the gay community that argued to be taken out of an
New Hampshire and Vermont. At least five more U.S. states earlier diagnostic nosology, the trans community has adopted
are expected to follow suit in the next few years. Israel now similar normalizing arguments to make the case for removal.
recognizes same-sex marriages performed in other countries. These include:
Similarly, while New York State and Rhode Island do not
• adopting normalizing etiological theories, such as the
presently allow same-sex couples to marry, they recognize gay
belief that one is born gay/trans;
marriages performed elsewhere. Civil unions for same-sex
• adopting a transhistorical approach that connects modern
couples in New Jersey may soon be upgraded to marriage. This
gay/trans identities to historical figures and cultures;
progress has been significant, despite some energetic counter-
• using modern cross-cultural studies to show that antiho-
movements, such as the federal Definition of Marriage Act
mosexual/antitrans attitudes are culture bound;
(DOMA), with many recent U.S. state constitutional amend-
• looking to statistics regarding prevalence to refute the
ments, and the 2008 referendum overturning California’s
notion that homosexuality/transgenderism is rare;
Proposition 8. U.S. states with domestic partnerships include
• underscoring the difficult, if not impossible task of changing
California, Hawaii, Maine, Oregon, and Washington. Numer-
a sexual orientation/gender identity, even through psycho-
ous local municipalities and corporations throughout North
therapeutic means;
America, Europe, and Latin America offer some form of
• adopting and insisting upon the use of normative language
legal relationship rights for same-sex couples. In addition to
to replace medical terminology (‘‘homosexuals’’ become
upgrading their current civil unions law to offering full
gay or defiantly queer; ‘‘gender dysphoria’’ becomes gender
marriage equality, many national and state governments are
dissonance; ‘‘gender reassignment surgery’’ becomes gen-
also addressing the rights of same-sex couples to adopt and to
der confirmation, gender affirmation surgery, genital reas-
act as foster parents to children. These events are the result of
signment surgery, or bottom surgery);
changing cultural norms and they have had a significant im-
• labeling theories that contradict affirmative perspectives
pact in rapidly changing cultural views on ‘‘appropriate’’
as unscientific;
expressions of gender as well.
• ad hominem and ad feminam attacks on professionals
The movement for transgender civil rights has followed
who either believe homosexuality/transgenderism is an
more slowly in the wake of the larger gay rights movement,
illness or use pathologizing language to make sense of
although the pace of the latter has picked up remarkably in the
homosexuality/transgenderism.
last decade. In the 1970s, with rare exceptions, local munici-
palities offering anti-discrimination protections on the basis of Given the sensitivities involved and the civil rights issues
sexual orientation did not include gender identity protections at stake, the push for a normative view of transgenderism, as
(National Gay & Lesbian Task Force, 2007). By the late 1990s, in the case of homosexuality almost four decades ago, has led
as trans inclusion became a focus of LGBT civil rights organi- to passionate and, at times polemical, calls for a reconsider-
zations, it was rare to find a state or municipality that did not ation of the GID diagnoses:
introduce anti-discrimination protections for sexual orientation
Ironically, psychiatric diagnosis has also served a human-
and gender identity at the same time.65 In recent years, anti-
istic purpose, sometimes for the same groups that it op-
discrimination protections and/or hate crime laws for gender
presses. Psychiatric classification can initially increase
identity have been enacted at the statewide level in California
public empathy for people who are seen as suffering from
(2003), Colorado (2005), Connecticut (2004), Hawaii (2003),
a ‘‘disease’’ and can even enable oppressed groups to be
Illinois (2005), Iowa (2007), Maine (2005), New Jersey (2006),
treated more humanely, but classification comes at the
New Mexico (2003), Oregon (2007), Pennsylvania (2002), Ver-
cost of reinforcing the belief that certain behaviors are
mont (2007), and Washington (2006) (National Gay & Lesbian
deviant, subnormal, or pathological, and therefore less
Task Force, 2008).66
deserving of genuinely equal rights. Thus, the removal of
65
homosexuality from the DSM was a watershed event
New York State is a notable exception.
66
in gay rights history and it foreshadowed the direction of
Relationships between the transgender and the rest of the LGB com-
munity have not always been harmonious. Wilchins (1997), for exam- the transgender rights movement today… [T]rans people
ple, recounts being excluded, during the 1990s, by lesbians at the Michi- have largely stopped thinking of themselves as ‘‘disorder-
gan Womyn’s Music Festival, a mostly lesbian organization that to this ed’’ or suffering from a ‘‘psychiatric disease.’’ They are
date apparently continues to exclude trans women from open partici- not as likely to have an uncritical gratitude towards the
pation.
123
Arch Sex Behav (2010) 39:427–460 445
benevolent and sometimes not so benevolent healers Much as the gay liberation movement spent many years
who are the gatekeepers of medical services. Mental hea- citing the Kinsey studies’ ‘‘10%’’ statistic to argue that their
lth professionals are especially problematic for those who numbers were too large to be ignored, trans activists also see
want body modification, because they control access to higher prevalence rates as both an antidote to invisibility as
surgeons and doctors who can prescribe hormones… well as furthering the cause of acceptance:
Transactivists are recognizing that pathologizing transg-
In this investigative report we calculate an approximate
enderism is, in the end, more harmful than helpful (Nic-
value of the lower bound of the prevalence of male-to-
hols, 2008, pp. 476–477).
female (MtF) transsexualism in the United States, based
Similar normalizing arguments, less polemical but no less on estimates of the numbers of sex reassignment sur-
passionate, are made by Winters (2005), who writes: geries performed on U.S. residents during the past four
decades. We find that the prevalence of SRS is at least on
The Gender Identity Disorder diagnosis has divided the
the order of 1:2500, and may be twice that value. We thus
transgender community and mental health professions
find that the intrinsic prevalence of MtF transsexualism
alike, on the premise that relief of social stigma associated
must be on the order of *1:500 and may be even larger
with psychosexual diagnosis must inevitably be traded
than that. We show that these results are consistent with
against access to sex reassignment procedures for those
studies of TS prevalence emerging in recent studies in
who require them. In truth, the current GID category fails
other countries. Our results stand is sharp contrast to the
transgender, and especially transitioning transsexual indi-
value of prevalence (1:30,000) so oft-quoted by ‘‘expert
viduals, on both counts. Gender variant people face barriers
authorities’’ in the U.S. psychiatric community to whom
to social legitimacy and civil rights under medical policy
the media turns for such information. We ponder why
that terms their gender identity as mental disorder and la-
that community might persist in quoting values of
bels ordinary gender expressions as sexual deviance. At the
prevalence that are roughly two full orders-of-magni-
same time, transsexual individuals who suffer gender
tude (a factor of *100) too small. Finally, we discuss the
dysphoria, that is distress with their physical sex charac-
challenge that our much larger and more realistic num-
teristics or their associated social roles, face obstacles to sex
bers present to the medical community, public health
reassignment treatment posed by a diagnosis of disordered
community, social welfare community and government
gender identity. By labeling a person’s identity, which is
bureaucracies (Conway, 2002).68
discordant with her or his natal sex, as disordered, GID
implies that identity and not the body is that which needs be Finally, in the tradition of queer theory, what constitutes
fixed. By its title and diagnostic criteria, the diagnosis ‘‘normal’’ gender is deconstructed from an outsider’s per-
contradicts treatment goals that correct the body (p. 72). spective. Just as heterosexuals were asked to look at their
heterosexism, transgender writers explicate cisgenderism or
In the tradition of Cass (1979), who created a model of gay
cissexualism to the less gender dissonant:
identity formation, Devor (2004) proposed a normalizing,
14-stage model of transsexual identity formation. Like an Perhaps the best way to describe how my subconscious
earlier generation of gay activists who turned to scientific sex feels to me is to say that it seems as if, on some level,
findings to support their movements normalizing arguments, my brain expects my body to be female. Indeed, there is
trans writers do so as well: some evidence to suggest that our brains have an intrinsic
understanding of what sex our bodies should be… When
There have also been studies that have examined a small,
one’s subconscious and conscious sexes match, as they do
sexually dimorphic region of the brain known as the
for cissexuals, an appropriate gender identity may emerge
BSTc. Researchers found that the structure of the BSTc
rather seamlessly. For me, the tension I felt between these
region in trans women more closely resembles that of
two disparate understandings of myself was wholly jar-
most women, while in trans men it resembles that of
ring… Many cissexual people seem to have a hard time
most men [Garcia-Falgueras & Swaab, 2008; Kruijver
accepting the idea that they too have a subconscious sex—
et al., 2000; Zhou, Hofman, Gooren, & Swaab, 1995].
a deep-rooted understanding of what sex their bodies
Like all brain research, such studies have certain limi-
should be. I suppose that when a person feels right in the
tations and caveats, but they do suggest that our brains
sex they were born into, they are never forced to locate or
may be hardwired to expect our bodies to be female or
male, independent of our socialization or the appear-
68
ance of our bodies (Serano, 2007, p. 81, italics added).67 In contrast, Van Kesteren, Gooren, and Megans (1996) estimate the
prevalence of transsexualism as 1 in 12,000 natal males and 1 in 30,000
natal females. As in the gay of GLB populations, transgender individuals
67
See Herbert (2008) for a discussion of the work of Garcia-Falgueras are frequently rendered invisible in population surveys (Drescher,
and Swaab (2008). 2009a).
123
446 Arch Sex Behav (2010) 39:427–460
question their subconscious sex, to differentiate it from Difficulty Finding Reconciling Language that Removes
their physical sex. In other words, their subconscious sex the Stigma of Diagnosis while Maintaining Access to
exists, but it is hidden from their view. They have a blind Medical Care
spot (Serano, 2007, pp. 80–87, my emphasis).
As in the case of EDH, there are voices seeking a middle
Table 1 lists some of the parallels between homosexuality
ground between avoiding the stigma of having a diagnosis
and gender variance as they relate to psychiatric diagnosis.
while at the same time justifying the need for medical and
surgical treatment. In an effort to resolve the contradictory
moral implications between narratives of pathology and
Homosexuality and GID: Contrasts
normal variation, conventional language can be stretched in a
variety of ways as a balance is sought between avoiding
Possibly Harmful Consequences of Removing GID
stigma and obtaining needed services and social concessions:
Gay activists of the mid-20th century were fighting both for It took the gay-rights movement 30 years to shift from
civil rights and sexual liberation. Toward that end, and to the Stonewall riots to gay marriage; now its transgender
keep medical practitioners from unnecessarily meddling in wing, long considered the most subversive, is striving for
gay people’s lives, most of them wanted out of the DSM. The suburban normalcy too. The change is fueled mostly by a
same approach is undoubtedly true for transgender people community of parents who, like many parents of this
who are not anatomically dysphoric and who therefore see no generation, are open to letting even preschool children
reason why mental health professionals should judge them in define their own needs. Faced with skeptical neighbors
the language of psychiatric diagnosis. and school officials, parents at the [Trans Health] con-
Among those who do seek to transition, there are activists ference discussed how to use the kind of quasi-thera-
and supporters who wish to retain the psychiatric diagnosis as peutic language that, these days, inspires deference: tell
a needed step in obtaining medical treatment. Some might the school the child has a ‘‘medical condition’’ or a ‘‘hor-
unfavorably be compared to Donald Webster Cory, an early monal imbalance’’ that can be treated later, suggested a
homophile activist who held a distinctly minority position conference speaker, Kim Pearson; using terms like gen-
that gay people should cooperate with psychiatrists in order to der-identity disorder or birth defect would be going too
obtain medical treatment of their homosexuality. far, she advised. The point was to take the situation out of
There are also trans activists who would prefer that psychi- the realm of deep pathology or mental illness, while at
atry not meddle in their decision to transition and that mental the same time separating it from voluntary behavior, and
health professionals should forego their currently assigned gate- to put it into the idiom of garden-variety ‘‘challenge.’’
keeping role of determining psychological fitness for transition. (Rosin, 2008)
As they seek a diminished role for psychiatry, they advocate for
From the perspective of clinicians, Levine and Solomon
increased access to physicians providing medical and surgical
(2009) self-consciously, and somewhat defensively, try to parse
care for transition. Some suggest placing transsexualism as
out the conflict between normal variant and pathological models
a ‘‘medical’’ rather than a ‘‘psychiatric’’ diagnosis of the ICD
of transsexualism. Although they say, ‘‘Our work begins with
(unlike the DSM, there is no American equivalent to the non-
the belief that GID is a fact of nature,’’ (p. 51), by which one
psychiatric section of the ICD). However, it is not clear whe-
might presume they think of transgenderism as a natural con-
ther such an approach would be amenable to the World Health
dition, they nevertheless assert:
Organization committees presently charged with updating the
ICD.69 1. In a nosological sense, GID are [sic] forms of psychopa-
Presently, however, where either insurance or national health thology;
care systems cover these procedures, it is a psychiatric diagnosis 2. Gender identity disorders are typically co-morbid with
that currently justifies ‘‘medical necessity’’ for such care. So other psychopathologies;
while removal from the DSM led to a liberating and immediate 3. The promotion of civil rights for the transgendered can
‘‘cure’’ (Drescher, 2002f) for members of the gay community, a obscure professional perceptions of psychopathology;
similar approach with GID could have unintended, adverse 4. Ethical obligations require professionals to communi-
treatment consequences, particularly for the anatomically dys- cate the uncertainties about the long-term outcome of gen-
phoric transgender individuals seeking or in need of medical der transition and sex reassignment surgery (SRS) (p. 41).
transition.
Levine and Solomon (2009) then go on to make a spirited
defense for retaining the language of psychopathology need-
69
The ICD is being revised for an 11th edition (ICD-11) scheduled for a ed as a separate category of discourse required for the clinical
2014 release. work. Despite the obvious narrative contradictions of their
123
Arch Sex Behav (2010) 39:427–460 447
Table 1 Homosexuality, gender variance and psychiatric diagnosis: parallels

Homosexuality Gender variance
Social justice as rationale for removal Yes Yes

Empirical basis as rationale for removal Yes Empirical data for both retention and removal are
(Sexology Research) controversial
Controversial at time of removal
Etiological theories reflect good and bad Normal Variation of Human Sexual Expression Normal Variation of Human Gender Expression
moral judgments Homosexuality is good and natural Transgender is good and natural
Psychopathology Psychopathology
Homosexuality is bad and the homosexual orientation Transgenderism is bad and the gender discordance
needs to be fixed needs to be fixed
Psychological Immaturity Psychological Immaturity
Homosexuality is bad and gay people need to grow up Transgenderism is bad and a form of arrested
development
Biblical condemnation Genesis 19 Deuteronomy 22:5
Leviticus 18:7, 22 Leviticus 22:24
Leviticus 20:13
Judges 19
I Kings 22:46
II Kings 23:7
Romans 1:27
I Corinthians 6:9
I Timothy 1:9–10
Modern religious attitudes Mostly condemning, with some religions and Mostly condemning, with some religions and
denominations more accepting denominations more accepting
Early normalizing theories Ulrich’s Urnings and Urningen, 1864 Ulrich’s Urnings and Urningen, 1864
Kertbeny’s ‘‘Homosexual,’’ 1869 Virginia Prince’s Transgenderist and
Havelock Ellis, 1905 Transgenderism, 1968
Magnus Hirschfeld, 1914
Medicalization, although stigmatizing, ‘‘The Homosexual’’ Krafft-Ebing, 1965 ‘‘Psychopathia Transsexualis,’’ Cauldwell, 1949
leads to wider social recognition and ‘‘The Invert’’ Freud, 1905 ‘‘Blissful Symbiosis’’ Stoller, 1964
acceptance of category of person
The Homosexual Neurosis Stekel, 1922 ‘‘The Transsexual Phenomenon’’ Harry Benjamin,
‘‘The Pervert’’ Rado, 1940 1966
‘‘Transsexualism’’ DSM-III, 1980
‘‘GID of Adulthood & Adolescence’’ DSM-IV,
1994
Theories of immaturity Freud, 1905 Stoller, 1968
Members of stigmatized group accept Illness and immaturity preferable to sin Illness model provides rationale for medical
medical labels Illness model offers hope of ‘‘cure’’ interventions facilitating transition
Immaturity model offers hope of ‘‘growth’’
Later normalizing theories Kinsey Reports, 1948, 1953 Denny, 1992
Ford and Beach, 1951 Devor, 2004
Evelyn Hooker, 1957 Serano, 2007
Cass, 1979
Members of stigmatized group reject Diagnoses seen as patronizing, demeaning and Diagnoses seen as patronizing, demeaning and
medical labels perpetuating of stigma perpetuating of stigma
Diagnostic category used to justify Immigration law, military service, marriage, Americans with Disability Act (ADA) specifically
discrimination adoption, inheritance and other taxes, insurance, excludes transsexualism; Refusal of life and
medical benefits disability insurance benefits
Social consequences of removing GLB individuals relieved of mental disorder label; Trans individuals who are not anatomically
Diagnosis from DSM Loss of rationalization for denying full equality in dysphoric relieved of mental disorder label; Loss
immigration, work, marriage, family law, etc. of rationalization for denying full equality in
immigration, work, marriage, family law, etc.
123
448 Arch Sex Behav (2010) 39:427–460
approach, they argue that such language should imply no orientation.’’70 In 1992, APA called on ‘‘all international
moral judgments about the patients: health organizations, psychiatric organizations, and individ-
ual psychiatrists in other countries to urge the repeal in their
There are three advantages to the designation of a
own countries of legislation that penalizes homosexual acts
pattern of behavior as a disorder. The first is that pro-
by consenting adults in private.’’71
fessionals with a scientific background are more likely
In 1998, APA issued a statement opposing ‘‘any psychi-
to study the origins, consequences, and treatment of
atric treatment, such as ‘reparative’ or ‘conversion’ therapy,
disorders than other patterns. Scientific study offers the
that is based on the assumption that homosexuality per se is a
possibility of new knowledge and efficacious treatment
mental disorder or is based on the a priori assumption that the
based on evidence. The second is that third-party pay-
patient should change his or her homosexual orientation.’’72
ment for evaluation and therapy services is linked to
In 2000, APA strengthened the statement, recommending,
diagnoses. There is no insurance coverage for unofficial
‘‘ethical practitioners refrain from attempts to change indi-
problems. The third is that some of the suffering atten-
viduals’ sexual orientation (American Psychiatric Associa-
dant to these patterns can be ameliorated (pp. 43–44).
tion, 2000b).’’73
To repeat, efforts to straddle the contradictory implica- Then, in 2000, following Vermont’s passage of civil un-
tions of having a diagnosis (bad, disordered) while putting ions laws, APA endorsed ‘‘the legal recognition of same-sex
forth a narrative of normal variation (good, natural) can be unions and their associated legal rights, benefits and respon-
seen as trying to foster an environment in which offering sibilities.’’74 In 2002, APA called for ‘‘initiatives allowing
medical and surgical treatment does not imply stigma or same-sex couples to adopt and co-parent children and sup-
judgment. ports all the associated legal rights, benefits, and responsi-
The Washington Psychiatric Society (2009) Task Force on bilities which arrive from such initiatives.’’75
Gender Identity Disorder similarly struggles to find language In 2003, APA signed onto an amicus brief for the gay
that ‘‘maximizes’’ access to medical, surgical, and mental health plaintiffs in the US Supreme Court case of Lawrence and
care while mitigating the potentially discriminatory uses of the Garner v. Texas. This historic Supreme Court decision abol-
diagnostic categories to restrict access to public accommoda- ished discriminatory US sodomy laws that criminalized
tions. The report notes, ‘‘In the current absence of means to homosexuality.76
resolve this dilemma satisfactorily (e.g., structural reform of the In 2005, after Massachusetts’ 2004 legalization of mar-
health care system), we propose revisions to the diagnostic riage equality, APA issued a statement supporting ‘‘the legal
categories available to care for gender variant persons’’ (pp. 1–2). recognition of same-sex civil marriage with all rights, ben-
In their struggle to find reconciling language, they even efits and responsibilities conferred by civil marriage, and
propose what might be called a ‘‘bookkeeping’’ solution: that opposes restrictions to those same rights, benefits, and
GIDC be removed from the DSM and replaced with the responsibilities.’’77
V-Code of Child/Adolescent Gender Variance. This diag-
nosis would be applicable until age 18 and presumably flag 70
Retrieved November 9, 2008 from http://www.psych.org/Departments/
those gender variant children (and their families) who seek EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/
some form of psychological treatment. While this would 199013.aspx.
71
reduce stigma by defining gender variance before age 18 as a Retrieved November 9, 2008 from http://www.psych.org/Departments/
subject of clinical attention rather than a psychiatric disorder, 199216.aspx.
the redefinition would only exacerbate the access to care 72
problem as third party payers rarely reimburse V-codes. EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/
199820.aspx.
73
APA and LGBT Civil Rights Retrieved November 9, 2008 from http://www.psych.org/Departments/
200001.aspx.
Following the events of 1973 and with subsequent genera- 74
tional changes in the organization, APA gradually became a EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/
more socially conscious group. Given psychiatry’s historical 200003.aspx.
75
role in stigmatizing homosexuality in mind, and thanks to the Retrieved November 9, 2008 from http://www.psych.org/Departments/
efforts of a growing number of openly gay, lesbian, and bisex- EDU/Library/APAOfficialDocumentsandRelated/PositionStatements/
200214.aspx.
ual psychiatrists coming out in the organization (Ashley, 76
Lawrence v Texas, retrieved November 9, 2008 from http://www.
2002; Barber, 2003, 2008; Hire, 2001), APA continued to
law.cornell.edu/supct/html/02-102.ZS.html.
expand its public positions regarding gay and lesbian civil 77
Retrieved November 9, 2008 from http://www.psych.org/Depart
rights. In 1990, APA issued a statement opposing ‘‘exclusion ments/EDU/Library/APAOfficialDocumentsandRelated/PositionState
and dismissal from the armed services on the basis of sexual ments/200502.aspx.
123
Arch Sex Behav (2010) 39:427–460 449
In 2006, APA created the John Fryer Award for ‘‘a public (3) A clear distinction between homosexuality and GID
figure who has made significant contributions to LGBT men- must be made in the next DSM.
tal health.’’ Named for the once-disguised Dr. H Anonymous’ (4) To avoid nosologic confusion between GID categories
alter ego, the award’s first recipients were Frank Kameny and in adults and children and to remove unfounded etio-
Barbara Gittings, two of the gay activists who 35 years ear- logic links between the two, we should separate the dia-
lier brought the issue of psychiatric stigmatization of homo- gnosis of GID in children from GID in adults.
sexuality to APA’s attention (Gittings, 2008).78 (5) That a scientific dialogue be established among members
The Caucus of Gay, Lesbian, and Bisexual Members of the of the transgender community, interested APA mem-
American Psychiatric Association (CGLBM-APA) was estab- bers, and the DSM-V Committees on GID.
lished in the mid 1970s and is active within APA to this day.79 In
The draft report appears not to have been widely distributed
1978, APA created a task force on gay and lesbian issues that in
within APA and is not accessible via a search of APA’s website.
1981 was upgraded to a standing Committee on Gay, Lesbian and
To this author’s knowledge, no action was taken on any of the
Bisexual (GLB) Issues. While originally charged to focus on
report’s recommendations. In fact, prior to the recent DSM
GLB issues, a revised charge was approved and updated in 2004
controversies (Chibbaro, 2008; Osborne, 2008), APA’s only
to include trans issues as well.80 Due to a 2009 restructuring of
official public statements regarding transgender people are the
APA governance, the Committee on GLB issues (among scores
DSM’s GID diagnoses and transvestic fetishism.
of others) was ‘‘sunsetted’’ and the GLB Caucus is now the de
Further, while it is often asserted that the DSM (and ICD)
facto APA component charged with addressing LGBT issues.
diagnoses provide the only pathways to insurance reimburse-
It contrast to its strong affirmation of LGB civil rights after
ment for trans individuals seeking medical assistance, APA has
the 1973 decision to remove homosexuality from the DSM,
issued no treatment guidelines for either GIDC or adult GID.
APA has not issued position statements in support of trans-
This omission is in stark contrast to an increasing proliferation of
gender civil rights. One explanation for this disparity may be
APA practice guidelines for other DSM diagnoses.81 In addi-
that there are hundreds of openly LGB psychiatrists advocating
tion, the absence of a formal APA opinion about treatment of a
for organizational awareness of LGB rights, both within APA as
diagnosis of its own creation has contributed to an ongoing,
well as in its allied organization, the Association of Gay and
troubling problem: many health care insurers and other third
Lesbian Psychiatrists (AGLP). There are very few visible trans
party payers claim that SRS is an ‘‘experimental treatment,’’ an
psychiatrists within either organization.
‘‘elective treatment,’’ or ‘‘not medically necessary’’ and there-
The Committee on Gay, Lesbian, and Bisexual Issues
fore not reimbursable or covered under most insurance plans
often functioned as the default clearinghouse for queries to
and treatment is not always accessible to wards of governmental
the APA about trans issues; however, in 1997 the Committee
agencies, such as foster care and prison systems. In other words,
drafted a Committee Report: The Diagnostic Category of
the presence of the GID diagnosis in the DSM is not serving its
Gender Identity Disorder (GID) (Committee on Gay, Les-
intended purpose of creating greater access to care—one of the
bian, and Bisexual Issues, 1997). Its heretofore unpublished
major arguments for diagnostic retention.
recommendations included:
In an effort to address this longstanding omission, APA’s
(1) That the assumptions fueling the conceptual confusions Board of Trustees voted in December 2007 to create a special
in the GID diagnosis be examined through the creation of Task Force to review the scientific and clinical literature on
an APA task force composed of members from APA’s the treatment of GID. That Task Force was convened in 2008
Committees on Women, Abuse and Misuse of Psychiatry and is presently reviewing the published literature on treat-
in the US, DSM, Gay, Lesbian and Bisexual Issues, Com- ment issues.
ponents of the Council on Children, Adolescents and Fam- Table 2 lists some of the contrasts between homosexuality
ilies, and transgendered members of the APA. and gender variance as they relate to psychiatric diagnosis.
(2) That documentation of possible misuses of the GID
diagnosis must be substantiated. Misuses should be add-
ressed, perhaps by the Ethics Committee.
81
APA has issued Practice Guidelines for Acute Stress Disorder and
78 Posttraumatic Stress Disorder, Alzheimer’s Disease and Other Demen-
Subsequent winners of the Fryer award were Lawrence Hartmann,
tias of Late Life, Borderline Personality Disorder, Bipolar Disorder,
MD (2007), Richard C. Pillard, MD (2008), and San Francisco Mayor
Delirium, Eating Disorders, HIV/AIDS, Major Depressive Disorder,
Gavin Newsome (2009).
79
Panic Disorder, Psychiatric Evaluation of Adults, Schizophrenia, Sub-
See http://www.aglp.org/pages/chistory.html. stance Use Disorders and Suicide. The American Psychological Asso-
80
This author chaired the APA Committee on GLB Issues from 2000 to ciation has recently issued a report recommending clinical approaches
2006 and fielded numerous questions from journalists and advocacy to gender dysphoric and gender variant patients (APA Task Force on
groups regarding APA positions on gender identity and transsexualism. Gender Identity and Gender Variance, 2008).
123
450 Arch Sex Behav (2010) 39:427–460
Table 2 Homosexuality, gender variance and psychiatric diagnosis: contrasts

Homosexuality Gender variance
Year placed in DSM 1952 (DSM-I) 1980 (DSM-III)

Current status as DSM Mental No GID
Disorder GIDC
Transvestic fetishism
Year removed from DSM 1973 N.A.
Homosexuality removed from DSM-II and
replaced by Sexual Orientation Disturbance
1980
Sexual Orientation Disturbance replaced by
Ego Dystonic Homosexuality in DSM-III
1987
Ego Dystonic Homosexuality removed in
newly revised DSM-III-R
Scientific rationale for diagnostic Alternative model to prevailing religious Alternative to prevailing psychiatric model of
category views of homosexuality as sin or immorality transsexualism as a symptom of psychosis or severe
neurosis
Medical rationale for diagnostic Diagnosis justified psychiatric interventions Diagnosis justified providing medical and surgical
category aimed at changing homosexual orientations treatment to enable transition
Presence of diagnosis in DSM has N.A. Limited success in US where most third party payers
increased access to care do not cover treatment of the diagnosis. Greater
success in other countries (using ICD) where
national health care systems pay for treatment
The role of activism Catalyzed 1970–1973 APA debates that Impact on status of GID diagnoses in DSM-V
eventually led to 1973 removal of uncertain
homosexuality from DSM-II
Medical consequences of No immediate medical consequences—DSM Possible loss of access to care—where third party
Removing Diagnosis from DSM text has remained mostly silent on sexual payment is available, it depends upon meeting
orientation as an associated factor (like race, current diagnostic criteria
age, ethnicity) in psychiatric disorders
Reconciling language to remove N.A. Difficult to reconcile
stigma of diagnosis while
maintaining access to medical
care
Chronological relationship between Civil rights advances gradually followed Civil rights advances have proceeded despite
place in DSM and civil rights removal from DSM inclusion in DSM
advances
APA Practice Guidelines offering N.A. None, despite inclusion in DSM for almost 30 years;
professional guidance regarding Board of Trustees authorized creation of Task Force to
treatment explore this issue in 2007
APA position statements in support Opposes discrimination in work and housing None
of civil rights (1974)
Opposes discrimination in the US Armed
Forces (1990)
Calls for repeal of antihomosexual laws in
other countries (1994)
Opposes conversion therapies (1998, 2000)
Supports second parent adoptions (2002)
Supports civil marriage equality (2005)
APA components charged with Caucus of Gay, Lesbian, and Bisexual None
advocating for minority groups Members (CGLBM-APA)
Committee on Gay, Lesbian and Bisexual
Issues (1981–2009)
123
Arch Sex Behav (2010) 39:427–460 451
Are Clinical Interventions with Gender Variant Children Each one of us, man and woman alike, is driven by the
Reparative Therapy?82 power of romantic love. These infatuations gain their
power from the unconscious drive to become a com-
This author has written and edited numerous reviews and plete human being. In heterosexuals, it is the drive to
criticisms of so-called reparative therapies and other sexual bring together the male-female polarity through the
orientation conversion efforts (Drescher, 1997, 1998a, 1998b, longing for the other-than me. But in homosexuals, it is
1998c; 2001, 2002c, 2002d; Drescher & Zucker, 2006). the attempt to fulfill a deficit in wholeness of one’s
However, this author’s understanding of that literature had not original gender (p. 109).
previously understood the term as applying to the prevention
Some significant contrasts between reparative therapists
of adult transsexualism in gender variant children.
and DSM-V Workgroup members who treat gender variant
Historically, there have been a range of theoretical and clini-
children are that none of the latter practice from a religious
cal approaches to changing homosexuality, i.e., psychoanalysis,
orientation, their published works do not explicitly cite reli-
aversion therapy, behavioral techniques, etc. The American
gious dogma, they do not think homosexuality is a sin or an
Psychological Association’s Task Force on Appropriate Ther-
illness, they do not think it is wrong to be gay, they do not see a
apeutic Responses to Sexual Orientation (2009) reviews all
gay outcome as a treatment failure, they do not call what they
these approaches and classifies them with the overarching term
do reparative therapy, and they do not reference reparative
‘‘Sexual Orientation Change Efforts’’ (SOCE).83
therapy literature in support of their clinical approaches.84 It
For purposes of conciseness, the term ‘‘reparative therapy’’ is
may also be true that reparative therapists may cite references
a subset of SOCE and primarily associated with the work of
from DSM-V Workgroup members, but distorting the findings
Nicolosi (1991). A fusion of religion and older psychoanalytic
of mainstream researchers in support of their controversial
theories of homosexuality, reparative therapy interventions for
approaches is not an uncommon practice among advocates and
‘‘treating’’ male homosexuality are based on a developmental
practitioners of conversion therapy (Drescher, 2002d, 2009b).
theory that claims a ‘‘failure to fully gender identify [with male
It appears that labeling these clinical practices as ‘‘repar-
figures leads to a] deficit in sense of personal power. Homo-
ative therapy’’ primarily rests on the analogy that trying to
sexuality is understood to represent the drive to repair the ori-
change an individual’s gender identity (gender identity con-
ginal gender-identity injury’’ (p. xvi). Homosexuality, in this
version efforts or GICE85) means the same thing as trying to
model, is analogized to vitamin deficiency diseases, in which the
change an individual’s sexual orientation (SOCE).
missing ingredients that ‘‘make people gay’’ are ‘‘good enough
What is the source of the comparison? The earliest reference
relationships’’ with one’s same-sex parent. Reparative ther-
in a scholarly publication is not in a review article or study, but a
apists claim their interventions repair or ‘‘heal’’ these putative
letter to the editor of the Journal of the American Academy of
‘‘deficits.’’
Child and Adolescent Psychiatry. There, Pickstone-Taylor
Nicolosi’s reparative therapy has roots, beginning in the
(2003) criticized Bradley and Zucker’s (1997) report of treating
1970s, in efforts to provide pastoral care to ‘‘homosexuals’’
gender variant children and compares their work to reparative
despite long-standing Christian beliefs about the special sin-
therapy of homosexuality. However, Pickstone-Taylor’s letter
fulness of same-sex thoughts, attractions, and behaviors (Er-
makes no mention of the religious or other theoretical beliefs
zen, 2006; Harvey, 1987; Moberly, 1983a, 1983b). Reparative
underlying reparative therapies but instead focuses on what he
theorists are quite straightforward in their belief that homo-
sees as analogous efforts to reinforce gender conformity in adult
sexuality is a mental disorder and a social problem. For exam-
gay patients and in gender variant children. Winters (2005, p.
ple, Moberly (1983a) asserts, ‘‘Traditionally, the Christian
77), in her critical discussion of Bradley and Zucker’s work with
faith has regarded homosexual activity as inappropriate, as
children, cites APA and other organizations’ policies against
contrary to the will and purposes of God for mankind…it
reparative therapies. However, none of those professional pol-
seems to the present writer that one may not avoid the con-
icy statements explicitly address the ethics or efficacy of efforts
clusion that homosexual acts are always condemned and never
to change gender identity in children. Hill, Rozanski, Carfag-
approved. The need for reassessment is not to be found at this
nini, and Willoughby (2007, p. 61) also describe efforts to chan-
point’’ (p. 27). In a similar vein, Nicolosi (1991) sees human
ge gender variant children as ‘‘reparative therapy.’’ While their
sexuality through a metaphysical lens that elevates hetero-
positions may be valid, these authors do not provide any details
sexuality and denigrates same-sex relationships:
to support the analogy. Further, at present there is no scholarly
82
At the request of the GID subgroup of the Workgroup on Sexual and
Gender Identity Disorders, and because of expertise in the area of sexual
84
orientation conversion efforts, this author has included this brief digres- For example, see Zucker (2000, 2005, 2006) and Bradley and Zucker
sion from the main issues addressed in this review. (2003).
83 85
The author served as a member of that American Psychological Kelley Winters (personal communication) has recently suggested the
Association Task Force. term.
123
452 Arch Sex Behav (2010) 39:427–460
literature to support the comparison. Why call them ‘‘reparative Subjective considerations were not entirely lost on the
therapy?’’ architect of the current DSM diagnostic system, Robert Spitzer
Certainly, the political benefits of the analogy seem unde- (1981), who struggled with similar questions decades ago:
niable. Given the small size of the transgender community,
The concept of disorder is man-made. Over the course of
mobilizing opposition to ‘‘reparative therapy,’’ a perennial beˆte
time, all cultures have evolved concepts of illness or dis-
noire of the larger LGB community provides a useful political
ease in order to identify certain conditions that, because of
shorthand: trying to change trans kids is obviously just like
their negative consequences, implicitly have a call to ac-
trying to change gay adults. Yet, as politically compelling as it
tion to a special group of caretakers (in our society, the
may be to assert that changing sexual orientation means the
health professions to provide treatment), to the person
same thing as changing gender identity, the analogy is prob-
with the condition (to assume the sick or patient role), and
lematic in other situations. For example, civil rights protections
to society (to provide a means for delivery of health care
based on sexual orientation do not provide civil rights protec-
and in some instances to exempt the sick individual from
tions for transgender individuals. If they did, there would be
certain responsibilities). The advantage of identifying
no need to seek more inclusive language protecting ‘‘gender
such conditions is that it makes it easier for individuals
identity’’ in civil rights legislation.
with those conditions to receive care that may be helpful to
This author believes a more detailed and scholarly study of
them. When the reasons for identifying certain conditions
potential harm from GICE and how that may compare with
as mental or physical disorders are understood, it will be
SOCE seems worthwhile. Hopefully, this challenging work
apparent that the question, ‘‘Is condition A (whether it be
will be taken up by interested colleagues who wish to im-
homosexuality, schizophrenia, left-handedness, or illit-
merse themselves in both the reparative therapy literature as
eracy) a disorder?’’ is more precisely stated as, ‘‘Is it useful
well as the literature on clinical interventions to change gen-
to conceptualize condition A as a disorder?’’ or, ‘‘What
der variant children. However, such a review is beyond the
are the consequences (to society, the individual with the
scope of this paper.
condition, and the health professions) of conceptualizing
condition A as a disorder?’’ (p. 211)
Discussion Spitzer, charged with answering the question of whether
homosexuality should be considered a psychiatric diagnosis,
As this review has tried to show, there are similarities and dif- came up with a unique formulation: psychiatric disorders are
ferences in the histories of diagnosing homosexuality and characterized by dysfunction and distress. Prior to that time,
gender variance as mental disorders. These histories underscore psychiatrists had no such formulation nor is it clear how much
the fact that many, if not all, diagnostic categories have a social interest they had in the question of how to define what is and
context. The most extreme examples of abusive authority cre- what is not a disorder. This is because both the DSM-I and -II
ating psychiatric diagnoses for purposes of exercising power represented an accretion of psychosocial problems brought into
and control are always jarring, as in the case of diagnosing psychiatric practice. Diagnoses were there because they repre-
escaped slaves in the antebellum South or ‘‘hospitalizing’’ sented phenomena that psychiatrists treated and what psychia-
political dissidents in the former Soviet Union and in other trists treated was based on the field’s origins in medicine and
authoritarian regimes. penology. Spitzer sought to create a more unified approach, one
Gay activists in the mid-20th century certainly viewed the that would diminish the influence of meta-psychological psy-
homosexuality diagnosis as an abuse of psychiatric authority choanalytic formulations on psychiatric diagnosis and link the
and there are activists in the LGBT community who view the DSM to contemporary scientific research models and to the
GID diagnoses in the same way. Given their potential for empirically based practices of other medical specialties. Fur-
abuse, some have called for eradicating psychiatric diagnoses ther, and to his credit, he also included so called V-Codes,
altogether. Such a move is highly unlikely and, in any event, acknowledging that not all problems presented to psychiatrists
doing so is likely to increase rather than diminish human rose to the level of a psychiatric diagnosis.
suffering. Some have sought to discredit psychiatric diag- In recognition of the fact that ‘‘disorders’’ occur in a
noses, regardless of their clinical utility, because all diag- psychosocial matrix, the Introduction of the DSM-III (APA,
noses are subjective and argue that psychiatric nosology is at 1980) notes:
best a ‘‘soft science’’ and, at worst, not a science at all. Yet the
In DSM-III each of the mental disorders is conceptu-
criticism of ‘‘subjectivity’’ can apply to even the ‘‘hardest’’ of
alized as a clinically significant behavioral or psycho-
sciences, as when the International Astronomical Union re-
logical syndrome or pattern that occurs in an individual
cently decided, by a membership vote, that Pluto is no longer
and that is typically associated with either a painful symp-
a planet (Vedantam, 2006).
123
Arch Sex Behav (2010) 39:427–460 453
tom (distress) or impairment in one or more important found themselves four decades ago. In fact, many of the
areas of functioning (disability). In addition, there is an changes in gender beliefs wrought by the gay rights move-
inference that there is a behavioral, psychological, or ment have altered social discourse and society’s values in
biological dysfunction, and that the disturbance is not ways that have created opportunities for the trans community
only in the relationship between the individual and so- as well. In contrast to the obstructive role the diagnosis of
ciety. (When the disturbance is limited to a conflict homosexuality played in gay people’s lives, and despite the
between an individual and society, this may represent persistence of trans diagnostic categories in both DSM and
social deviance, which may or may not be commend- the ICD-10, the social acceptance of transgenderism and
able, but is not by itself a mental disorder.) (p. 6) articulation of transgender rights has increasingly unfolded
in both the U.S. and abroad (see Green, 2009b; NGLTF, 2007,
Psychiatric illnesses, like ‘‘social deviance,’’ often create 2008; Yogyakarta Principles, 2007). Growing recognition
conflicts between individuals and society. Consequently, both and increased acceptance to date should not be interpreted as
the psychiatrically ill and minority groups are subject to stig- a rationalization for retention of the diagnosis but only as a
ma. As noted in the WPATH Standards of Care (2001), ‘‘The statement of fact. Further, it is entirely possible that the lag-
designation of gender identity disorders as mental disorders is ging social acceptance of gender variance will catch up with
not a license for stigmatization, or for the deprivation of gender the more advanced social normalization of homosexuality.
patients’ civil rights’’ (p. 6). Stigmatization of individuals with For example, gay marriage, once unimaginable, is now the
psychiatric disorders is a social problem with which APA is law of the land in many places. It is not unthinkable that, in the
quite familiar. Organized psychiatry and other mental health future, gender variant people transitioning from one sex to
professionals have spent decades trying to reduce the stigma of another might be treated by medical specialists who, like
psychiatric illness in order to increase access to care and to obstetricians, use medical and surgical interventions to
encourage people to avail themselves of mental health ser- facilitate what society considers to be a normal life event.
vices. Mental health professions are themselves stigmatized How far is society from such a normalizing outcome?
because of their association with the conditions affecting the Forty years ago, it seemed unlikely that the average person
populations they treat. would have accepted the idea of gay marriage. Today, polls
It is, therefore, understandable that many transgender indi- show a majority of Americans support marriage equality
viduals, already stigmatized for their expressions of gender (Langer, 2009). In the United Kingdom, individuals who
variance, would wish to avoid the added burden of being la- have undergone reassignment can marry with the legal status
beled as having a ‘‘mental disorder.’’ This is especially true for of the post-operative sex (Green, 2009b). The situation is
members of the trans community who are not anatomically much grimmer in the U.S. where postoperative marriages by
dysphoric and who neither seek nor desire medical or surgical trans individuals have been annulled by court decree (Currah
intervention to change their bodies. Further, many in the trans et al., 2009). So although the psychosocial context for eval-
community who do seek medical intervention prefer being uating gender variance is rapidly changing, today there is a
diagnosed with a ‘‘medical condition,’’ rather than a psychi- practical concern that it might be difficult to convince most
atric disorder. Yet most psychiatrists today would argue that people that transition from one sex to another is as ‘‘normal’’
psychiatric disorders are medical conditions. One unintended as childbirth. That day may come, and in some places it has
consequence of belaboring distinctions between medicine and already arrived, most notably in those communities and
psychiatry, and this is a wider social problem faced by trans- schools that are increasingly supportive of allowing young
gender and cisgender people alike, is the perpetuation of gender variant children to adopt the gender role they feel is
existing stigma and prejudices against the psychiatrically ill. consistent with their gender identity (Kennedy, 2008; Rosin,
If the parallels between homosexuality and gender vari- 2008; Spiegel, 2008a, 2008b).86
ance are absolute, then social resistance to transgender civil What role should APA and the DSM play in changing
rights and transphobia in general are byproducts of the psy- society’s attitudes toward transgenderism? Bayer (1981), in
chiatric diagnoses and resultant stigma. In retrospect, the med- his analysis of the 1973 APA decision, believed ‘‘the psychi-
ical perpetuation of stigma was clear in the case of homo- atric mainstream must ultimately affirm the standards of health
sexuality. History has vindicated the efforts of those early gay and disease of the society within which it works. It cannot hold
activists who believed that removing that diagnosis from the to discordant views regarding the normal and abnormal, the
DSM would reduce their social stigma and elevate their so- desirable and undesirable, and continue to perform its socially
cial status. If that is also true of gender variance, then remov- sanctioned function’’ (p. 194). If that is true, psychiatry cannot
ing the GID diagnoses from DSM could accelerate trans so-
cial acceptance and tolerance. 86
Silverstein (2009) makes a similar argument that changing sexual
Today’s trans activism, however, is taking place in a much mores propelled by the growth of and exposure to Internet pornography
different climate than the environment in which gay activists will render obsolete contemporary cultural notions of paraphilias.
123
454 Arch Sex Behav (2010) 39:427–460
take a leadership role in changing social attitudes but must and adulthood? If so, is it advisable or ethical to treat children
instead merely follow or mirror society’s values. in order to prevent adult transsexualism? To whom does it
Bayer’s conclusions, however, proved to be in error,87 matter if a child grows up either gay or transgender? Does the
although it took the passage of a generation before society felt current state of empirical research support treating prepub-
the deeper effects of APA decision to remove homosexuality escent children with hormone blockers to prevent the onset of
from the DSM. After the 1973 APA decision denied reli- puberty and the facilitation of transition in later life? What of
gious, political, military, and educational institutions a medi- the gender variant child whose social environment both ac-
cal rationalization for discrimination, the debates surround- cepts and encourages an early transition but may be unaware
ing homosexuality shifted from the medical and scientific that the child, unwilling to disappoint, has had a change of
arenas to the social, political, and moral forums where they heart (P. T. Cohen-Kettenis, personal communication)? Who
properly belonged. Consequently, by the mid-1990s, Amer- should be designated as the best advocates for gender variant
ican policy makers at the highest levels of national and state children? Parents? Teachers? Government agencies? Mental
government were engaged in heated debates regarding mar- health professionals? Adult transgender activists? Queer
riage equality and the rights of gay people to serve in the theorists? These and many other questions not easily an-
military. It is entirely possible that removing GID from the swered and all will require further study as well as thoughtful
DSM would do the same for transgender rights. One should analysis and discussion.
not underestimate the stigma-reducing effect if being trans is
no longer considered a psychiatric disorder.
Yet, as a practical matter in the here and now, and as Meyer- Recommendations
Bahlburg (2009) details in a related review, removal could
have other consequences, specifically the loss of medical and How should APA proceed? Physicians need to take to heart
legal justifications for medical treatments facilitating transi- the dictum ‘‘first do no harm.’’ This guides many clinical en-
tion for anatomically dysphoric trans individuals. counters in which physicians and patients must make treat-
Last, but not least, this review has not taken up the issues ment choices, all of which are potentially fraught with harm.
surrounding the treatment and place of GIDC in the DSM. In those cases, the best approach is to make choices that
While there is a growing acceptance of treating adults who maximize benefits and minimize harm (or side effects). At
present for transition, the meaning and approach to gender this moment in time, I believe the less harmful choice would
variance in children and adolescents is more controversial. It be retaining and modifying the adolescent and adult GID
is beyond the scope of this paper to review those issues (see diagnostic criteria to make them more narrowly inclusive of
Bartlett, Vasey, & Bukowski, 2000; Cohen-Kettenis & individuals who are distressed about the dissonance between
Pfäfflin, 2009; Corbett 1996, 1998; Ehrbar, Witty, Ehrbar, & their anatomical and psychological gender.
Bockting, 2008; Hill et al., 2007; Isay, 1997; Kennedy, 2008; Given the potential for stigma, why retain the diagnosis at
Korte et al., 2008; Menvielle, Tuerk, & Perrin, 2005; Möller, all? As previously noted, unlike the case of homosexuality in
Schreier, Li, & Romer, 2009; Richardson, 1996, 1999; Wal- the 1970s, the expansion of trans rights has not been entirely
lien & Cohen-Kettenis, 2008; Zucker, 2008a, 2008b, 2009) obstructed by the DSM diagnoses, although it is entirely
but it is worth highlighting some of them. possible that the DSM diagnoses may have played (and are
Are all presentations of gender variance in children non- still playing) an inhibitory role delaying the pace of change.
pathological? Is the psychological distress associated with Yet, despite the GID diagnoses being on the books, the
gender incongruence in children the result of internal pro- acceleration of trans legal protections in the last decade has
cesses or unaccepting social responses? Is it possible to been rapid (NGLTF, 2007). While retaining the diagnoses,
clinically distinguish a pathological GIDC from normative even with modification, can undoubtedly contribute to per-
gender atypical behavior of children who may or may not petuating stigma (in a manner similar to being diagnosed with
grow up to be gay or transgender? Given that most cases of major depression or bipolar disorder can be stigmatizing),
childhood gender incongruence do not persist into adulthood, such an outcome would constitute a lesser harm to anatom-
are there subtypes of GIDC? If so, can they be distinguished ically dysphoric members of the trans community than the
from each other? Does empirical research support the claim denial of access to medical and surgical care likely to ensue
that clinical interventions with gender variant children can following removal from the DSM. However, narrowing
prevent persistence of gender incongruence into adolescence current DSM-IV-TR diagnostic criteria to exclude trans indi-
viduals who are not anatomically dysphoric nor distressed
87
APA has also played a significant leadership role in past decades in would also go a long way in reducing the stigma experienced
reducing social stigma associated with public conversations about psy-
by a sector of the trans community.
chiatric illnesses like depression and anxiety, in normalizing the use of
psychotropic medications, and in the growing cultural acceptance of The DSM-V Workgroup on Sexual and Gender Identity
‘‘talk therapies.’’ Disorders, the DSM-V Task Force, and the APA can take
123
Arch Sex Behav (2010) 39:427–460 455
steps to reduce the potential harm of stigmatization and im- DSM-V Advisors Richard Green and Lawrence Hartmann and William
prove access to needed medical care. Narrow, Research Director of the DSM-V Task Force, is greatly appre-
ciated. I am also grateful for innumerable conversations with and/or
Recommendations to the DSM-V Workgroup on Sexual helpful readings of earlier drafts of this article by Stewart Adelson, Kenn
and Gender Identity Disorders and the DSM-V Task Force Ashley, Mary Barber, Mark Blechner, Phillip Blumberg, William Byne,
include: James Cantor, Susan Coates, Dominic Davies, Ann D’Ercole, Ken Eisold,
Todd Essig, Michael First, Sally Herbert, John Kerr, Ubaldo Leli, Vittorio
• Modify the language of DSM-V GID diagnoses so they Lingiardi, William Lubart, Mark Maltz, Luisa Mantovani, Naomi Mark,
are less stigmatizing of gender variance in general; Scot McAfee, Benjamin McCommon, Joe Merlino, Shannon Minter,
Robert Mitchell, Robert Spitzer, Cathy Renna, Chris Sekaer, Serena
• Separate gender diagnoses from the sexual dysfunctions
Volpp, Jerome Wakefield, and Kelley Winters. Some of my patients also
and paraphilias; read earlier drafts of this article and I wish to thank them for their insights
• Separate any childhood diagnosis in the DSM-V from as well. Reprinted with permission from the Diagnostic and Statistical
adult transsexualism to avoid existing nosologic confu- Manual of Mental Disorders V Workgroup Reports (Copyright 2009),
sion between GID categories in adults and children;
• Narrow the DSM adolescent and adult GID criteria so that
the diagnosis only applies to individuals who are anatom-
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and demographic study of transsexuals in the Netherlands. parent counseling for gender identity disorder. In R. L. Spitzer, M.
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worldview. The Washington Post, p. A02. Retrieved May 4, 2009 321–334). Washington, DC: American Psychiatric Publishing.
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dyn/content/article/2006/08/27/AR2006082700644.html order in children [Editorial]. Journal of the American Academy of
Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008). Psychosexual Child and Adolescent Psychiatry, 47, 1361–1363.
outcome of gender-dysphoric children. Journal of the American Zucker, K. J. (2008b). Children with gender identity disorder: Is there a
Academy of Child and Adolescent Psychiatry, 47, 1413–1423. best practice? Neuropsychiatrie de l’enfance et de l’adolescence,
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DOI 10.1007/s10508-009-9532-4
ORIGINAL PAPER
From Mental Disorder to Iatrogenic Hypogonadism: Dilemmas

in Conceptualizing Gender Identity Variants as Psychiatric
Conditions
Heino F. L. Meyer-Bahlburg

Abstract Thecategorization ofgenderidentity variants (GIVs) Keywords Gender identity disorder Transsexualism
as ‘‘mental disorders’’ in the Diagnostic and Statistical Man- Transgenderism DSM-V Mental illness
ual of Mental Disorders (DSM) of the American Psychiatric
Association is highly controversial among professionals as
well as among persons with GIV. After providing a brief his- Introduction
tory of GIV categorizations in the DSM, this paper presents
some of the major issues of the ongoing debate: GIV as psy- During the preparation of the 5th edition of the Diagnostic
chopathology versus natural variation; definition of ‘‘impair- and Statistical Manual of Mental Disorders (DSM-V) of the
ment’’ and ‘‘distress’’ for GID; associated psychopathology American Psychiatric Association (APA), the often vehe-
and its relation to stigma; the stigma impact of the mental- ment exchanges among and between diverse stakeholders
disorder label itself; the unusual character of ‘‘sex reassign- show that the psychiatric categorization of gender identity
ment surgery’’ as a psychiatric treatment; and the consequences variants (GIVs) remains highly controversial. Among men-
for health and mental-health services if the disorder label is tal-health professionals as well as among gender-variant per-
removed. Finally, several categorization options are exam- sons the opinions range widely, from recommendations to
ined: Retaining the GID category, but possibly modifying its continue the inclusion of GIVs as ‘‘mental disorders’’ in the
grouping with other syndromes; narrowing the definition to DSM to demands for the complete removal of GIVs from the
dysphoria and taking ‘‘disorder’’ out of the label; categoriz- DSM altogether (see, for instance, the findings from a recent
ing GID as a neurological or medical rather than a psychiatric survey of transgender advocacy groups’ opinions by Vance
disorder; removing GID from both the DSM and the Inter- et al. [2009], as well as the report on a consensus confer-
national Classification of Diseases (ICD); and creating a ence of the World Professional Association for Transgender
special category for GIV in the DSM. I conclude that—as also Health by de Cuypere, Knudson, & Bockting, 2009). The pur-
evident in other DSM categories—the decision on the cate- pose of this paper is to examine concepts, pertinent data, ap-
gorization of GIVs cannot be achieved on a purely scientific parent dilemmas, and possible options for the resolution of
basis, and that a consensus for a pragmatic compromise needs these dilemmas.
to be arrived at that accommodates both scientific consider- The nomenclature in the area of sex and gender variations
ations and the service needs of persons with GIVs. continues to be in flux, in regard to both the descriptive gender
terms used by professionals and, even more so, the identity
terms adopted by persons with GIV. In this article, I will use
‘‘sex’’ to refer to the congenital somatic and physiological
aspects, and ‘‘gender’’ to denote the behavioral, psychological,
H. F. L. Meyer-Bahlburg (&) and social aspects (understood as the result of interacting bi-
New York State Psychiatric Institute and Department ological, psychological, and sociological factors) as well as the
of Psychiatry, Columbia University, legal categorization. At birth, a child’s ‘‘sex’’ is usually iden-
1051 Riverside Drive, Unit 15, New York,
NY 10032, USA
tified by the external genitalia and serves as the basis for the
e-mail: [email protected] assignment of legal ‘‘gender’’ with the expectation that the
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462 Arch Sex Behav (2010) 39:461–476
social environment will create a corresponding social ‘‘gender rights approach led to the formulation of the Yogyakarta
role’’ for the child and that the child will later develop ‘‘gender- Principles (2007) on the application of international human
related behavior’’ and a ‘‘gender identity’’ accordingly. In cases rights law to sexual orientation and gender identity, with fur-
of somatic disorders of sex development (DSD), a term that ther elaboration in subsequent publications (Currah, Green,
includes ‘‘intersexuality’’ along with other conditions, when & Stryker, 2009). Recent additional milestones in the U.S.
the external and internal genitalia are not unambiguously male were the Resolution 122 of the American Medical Associa-
or female, gender assignment results from a more complex tion (American Medical Association, 2008), ‘‘Removing
decision process (Meyer-Bahlburg, 2008). I refer to ‘‘gender Financial Barriers to Care for Transgender Patients’’ (where
variants’’ (GVs) as the entire spectrum of people with gender- GID is labeled a ‘‘serious medical condition’’), and a few
atypical behavior, to ‘‘gender identity variants’’ (GIVs) or weeks later the resolution of the American Psychological
‘‘transgender’’ as the entire spectrum of people who identify Association (2008a) on ‘‘Transgender, Gender Identity, and
with a gender category other than the one assigned to them at Gender Expression Non-Discrimination,’’ which followed
birth or shortly after (‘‘natal gender’’), and I use ‘‘gender identity the publication of the report of that society’s Task Force on
disorder’’ (GID) and ‘‘GID Not Otherwise Specified’’ (GID- Gender Identity and Gender Variance (2008b).
NOS) as defined in the DSM-IV-TR. During these past decades, persons with GIV increasingly
dared ‘‘coming out,’’ the GIV spectrum and related identities
diversified, and numerous communities of gender-atypical
persons developed and became more visible to the public at
History of Gender Variants in the DSM large.
During the same half century, also the terms and placement
Persons with varying degrees of gender-atypical develop- of GIV-related categories in the DSM underwent change.
ment have been described for many and diverse cultures (e.g., DSM-I (American Psychiatric Association, 1952) and DSM-II
Herdt, 1996; Whitam, 1997; Winter, 2009; for Brazil: Car- (American Psychiatric Association, 1968) had not included
doso, 2005; Inciardi, Surratt, Telles, & Pok, 1999; Kulick, specific terms for persons with GIV; some such individuals
1998; for India: Bradford, 1983; Nanda, 1999; for India and were subsumed under Sexual Deviations (e.g., Homosexuality
Sri Lanka: Stevenson, 1974; for Mexico: Stephen, 2002; for or Transvestism). Christine/George Jorgensen, for instance,
Myanmar: Coleman, Colgan, & Gooren, 1992; for Oman: was called a ‘‘genuine transvestite’’ (Hamburger et al., 1953).
Wikan, 1977; for Samoa: Bartlett & Vasey, 2006; Vasey & In DSM-III (American Psychiatric Association, 1980), the
Bartlett, 2007; for Thailand: Costa & Matzner, 2007; Jack- new category of GID, with the subcategories Transsexualism,
son, 1997; for the native Zuni culture in the U.S.: Roscoe, GID of Childhood, and Atypical GID, was placed in the group
1990) and throughout recorded history (Bullough & Bul- of Psychosexual Disorders. In DSM-III-R (American Psychi-
lough, 1993; Feinberg, 1996; Perry, 1987; Rowsen, 1991; atric Association, 1987), GID, now subdivided into ‘‘Trans-
Wiesner-Hanks, 2001). In American society, the extreme sexualism,’’ ‘‘GID of Childhood,’’ ‘‘GID of Adolescence and
variant involving gender reassignment, cross-gender hor- Adulthood, Nontranssexual Type’’ (GIDAANT), and ‘‘GID-
mone treatment, and genital surgery became a salient issue NOS,’’ was separated from Psychosexual Disorders and placed
with George/Christine Jorgensen in 1952 (Docter, 2007; under Disorders Usually First Evident in Infancy, Childhood, or
Hamburger, Stürup, & Dahl-Iversen, 1953), which was soon Adolescence. DSM-IV (American Psychiatric Association,
followed by clinical benchmark papers and books on the 1994) and DSM-IV-TR (American Psychiatric Association,
subject: Benjamin (1954), Green and Money (1960), Stoller 2000) created the supraordinate category ‘‘Sexual and Gender
(1964), Pauly (1965), Benjamin (1966), Green and Money Identity Disorders,’’ which included GID (with separately for-
(1969). In the mid-1960s, the first medical school-based mulated criteria for children and for adolescents/adults) and
transsexual clinic was opened at Johns Hopkins Hospital in GIDNOS. The DSM-IV text also introduced the term ‘‘auto-
Baltimore, MD. It was closed again as a consequence of an gynephilia’’ as a fetishistic feature ‘‘usually reported in the
ideological backlash in 1979, the same year which saw the history of adult males who are sexually attracted to females, to
founding of the Harry Benjamin Gender Dysphoria Associ- both males and females, or to neither sex.’’ This concept con-
ation (recently renamed the World Professional Association tinues to be highly controversial, and even among persons with
for Transgender Health), along with the distribution of its GID, opponents and proponents of its validity (including per-
first version of the Standards of Care (SOC). The first psychi- sons with GID who categorize themselves as autogynephilic)
atric category specific to GIV, ‘‘gender identity disorder,’’ can be found. Across all versions of the DSM since DSM-III, the
was introduced with DSM-III in 1980 (American Psychiat- core construct of GID is the combination of identification with
ric Association, 1980). In the legal domain, antidiscrimina- the other gender and of a sense of inappropriateness, if not
tion statutes were gradually extended to include persons with rejection, of one’s assignment to the natal gender, with the key
GIVs during the 1990s, and in 2007 the evolving human- specifiers of age (in terms of some age-specific criteria), gender
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Arch Sex Behav (2010) 39:461–476 463
(including some gender-specific criteria for childhood), and sex- pathologic category (e.g., Burke, 1996; Sedgwick, 1991).
ual orientation (for adolescents and adults). Despite its detailed repudiation by key participants in the
The current debates of GID and the DSM present some DSM process (Zucker & Spitzer, 2005), this conspiracy the-
striking parallels to the developments that led to the removal ory appears to continue its life as a politically potent legend
of homosexuality from the DSM in 1973. As described by (e.g., Ault & Brzuzy, 2009). In addition, there are some
Bayer (1981), prior to DSM-III, homosexuality was seen in developmental similarities of homosexuality and GID. Both
psychiatry as a pervasive mental disturbance. In the late sexual orientation and gender identity cover spectra between
1950s, Evelyn Hooker demonstrated the existence of overall the male-typical and female-typical (binary) poles. Homo-
well functioning homosexuals. Frank Kameny emphasized sexuality is to some extent associated with gender-atypical
the lack of scientific evidence for homosexuality as psycho- behavior. In fact, GID of childhood is a stronger predictor of
pathology and launched a protest movement against its clas- the development of homosexuality than of GID in adoles-
sification as a mental disorder. The eminent psychiatrist, Judd cence or adulthood (Bailey & Zucker, 1995; Mathy & Dre-
Marmor, declared homosexuality a ‘‘normal variant.’’ Robert scher, 2008), which, however, does not justify to concep-
Spitzer concluded that homosexuals can be high functioning tually equate GID and homosexuality, given their different
and satisfied with their sexual orientation. That insight con- developmental courses and frequent non-congruence. Fi-
tributed to Spitzer’s formulation of ‘‘impairment’’ and ‘‘dis- nally, both homosexuals and people with GIVs suffer exten-
tress’’ as defining features of a ‘‘mental disorder.’’ Robert sive societal stigma and, probably in part as a consequence,
Spitzer and Ronald Gold drafted the civil rights resolution increased psychiatric problems (Alanko et al., 2009; Lom-
opposing both criminal sanctions against private consensual bardi, Wilchins, Priesing, & Malouf, 2001; Meyer & North-
homosexual activity and social discrimination against homo- ridge, 2007; Nuttbrock et al., 2009b; Plöderl & Fartacek,
sexual men and women; this resolution was approved by the 2009; Ryan, Huebner, Diaz, & Sanchez, 2009; Winter, 2009),
American Psychiatric Association in December 1973, along although bidirectional causation cannot be ruled out. On the
with the deletion of (ego-syntonic) homosexuality from the other hand, there is a subgroup of persons with early-child-
DSM. hood GIV who settle into their assigned gender during later
Similarly, in the mid-twentieth century, GID was also seen childhood and, relative to their natal gender, develop heter-
as a pervasive mental disorder, by some even as a form of psy- osexuality. In addition, there are two major practical differ-
chosis (e.g., Siomopoulos, 1974). In the last 20 years, there ences between homosexuality and the transsexual degree of
has certainly been a growing recognition of transsexual men GIV, i.e., those who want to cross over the gender line
and women who are high-functioning and satisfied with their completely, namely (1) the wish to change one’s legal gender
adopted gender, i.e., people who seemed to show nei- status to the other, desired gender, and (2) the wish to conform
ther ‘‘impairment’’ nor ‘‘distress,’’ and therefore not a ‘‘mental one’s body to the desired gender by cross-gender hormone
disorder.’’ There is also a vigorous activist movement against treatment and genital surgery. In many countries, the perti-
the psychiatric categorization (‘‘pathologization’’) of trans- nent legal regulations for government action and insurance
gender individuals (e.g., Gender Spectrum Family; GID Re- coverage require the recognition of a clinical or psycho-
form Advocates; Professionals Concerned with Gender Diag- pathological condition that is attested to by a professional
noses in the DSM; Trans Youth Family Allies), which is specialist. Only persons with a somatic DSD, who request
strongly supported by activist members of gay and lesbian gender re-assignment and genital surgery, encounter less of a
communities. Many activists and a growing school of mental- regulatory hurdle, because they have a diagnosable somatic
health professionals (some of whom are transgender) see condition of disordered (biological) sex.
transgenderism as a ‘‘normal variant’’ between the gender
poles (Brill & Pepper, 2008; Hill, Rozanski, Carfagnini, &
Willoughby, 2007; Lev, 2005; Moser & Kleinplatz, 2005; Arguments for and against the Mental Disorder
Perrin, 2002). At the same time, an increasing number of Classification
jurisdictions extend human-rights based antidiscrimination
laws to include gender or transgender. Clearly, a number of Given the interrelationship of variations of gender and sexual
the facets of the current GIV debate replicate facets of the orientation and their intraindividual fluidity in some individ-
homosexuality debate of the 1960s–1970s (for greater detail, uals, as expressed, for example, in the term ‘‘genderqueer’’
see Drescher, 2009). (Bryant, 2008), it is no wonder that the psychiatric classifica-
The engagement of gay activists in the current political tion of marked GIVs has been strongly criticized. Some au-
debate is fueled, in part, by a lingering suspicion among many thors dismiss the psychiatric classification altogether (Isay,
that GID, especially GID of childhood, was deliberately put 1997) or, from a Foucaultian perspective, interpret the psy-
into the DSM as a cryptic way of retaining homosexuality as a chiatric diagnosis of GID as nothing but a ‘‘tool of social
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464 Arch Sex Behav (2010) 39:461–476
control’’ that serves ‘‘to pathologize ordinary human diversity’’ Stedman’s Medical Dictionary (1995) defines ‘‘pathology’’
(Lev, 2005). Others propose to distinguish between subgroups as the ‘‘medical science, and specialty practice, concerned
with and without psychopathology, for instance, in regard to with all aspects of disease, but with special reference to the
children with marked GVs (e.g., Bartlett, Vasey, & Bukowski, essential nature, causes, and development of abnormal con-
2000; Bockting & Ehrbar, 2005; Richardson, 1999), and to ditions, as well as the structural and functional changes that
apply psychiatric categories only to those with demonstrated result from the disease processes’’ (in Greek, pathos =feel-
psychopathology (other than GIV). ing, suffering disease; in Greek, logos = study, treatise). In
Hill et al. (2007) deduce from various findings of increased line with this definition, ‘‘psychopathology’’ is the ‘‘science
psychiatric problems in the parents of children with GIV that concerned with the pathology of the mind and behavior.’’
it may be the parents rather than their children who are psy- Yet, the Stedman definition of pathology obviously presup-
chiatrically disturbed (for a similar argument, see also Lev poses a consensus on the definition of ‘‘disease,’’ and does not
[2005]), and that such parents may bias their reports of their offer a systematic approach to demarcate psychopathologic
GIV children’s psychiatric problems. These authors fail to take from non-psychopathologic for the continua of behavioral
into consideration, however, that familiality and heritability domains which, at the extreme end, are categorized as psy-
are common findings in psychiatric conditions, which implies chiatric dysfunctions and/or mental disorders.
a contribution of biological components to their development. In regard to GIVs, part of the categorization problem is due
Moreover, even if environmental circumstances (including to the fact that we do not have a well established detailed
parent-child relationships) also contribute to the development theory—let alone a neuroanatomic/neurophysiologic mod-
of psychiatric disorders, as it is the case, for instance, in el—of normal gender identity development that gives us
posttraumatic stress disorder (PTSD), it is not meaningful to clear guidance in distinguishing non-pathologic from path-
deny their existence in the child. On the other hand, some stud- ologic. Apart from the gender assignment at birth on the basis
ies fail to identify parental problems as a major risk factor for of the appearance of the external genitalia, the developmental
GID development (e.g., Wallien, van den Langenberg, Knol, psychological processes leading to sex-dimorphic behavior,
Kreukels, & Cohen-Kettenis, in press). In regard to reporting gender schemas, and a gendered self-concept—presumably
bias, the multimethod and multiinformant approaches used in in dependence on central-nervous system organization as
the systematic clinical evaluations of children with GIVs (e.g., well as on various mechanisms of social learning—appear
Meyer-Bahlburg, 2002; Zucker & Bradley, 1995) show that to be highly intercorrelated (Ruble, Martin, & Berenbaum,
the reports by parents about their children usually are largely in 2006). Under these circumstances, causal directions among
line with the findings from children’s self reports and clini- psychological processes are notoriously difficult to establish,
cians’ observational evaluation of these children; they cannot, which makes the delineation of pathologic processes prob-
therefore, be attributed to mere parental bias against their lematic. Moreover, probably due to differences in study pop-
children as claimed by Hill et al. (2007). ulations, there is little overlap and communication between
In the often vociferous debates of the status of GIVs in the theorists of normal gender development (e.g., Egan & Perry,
DSM in professional journals and in statements from activist 2001; Ruble et al., 2006) and theorists of GIV. Biologically
groups, especially on the internet, a number of key issues have oriented investigators of GIVs tend to draw on models of
attained particular salience. Among these are: (1) Do GIVs behavior development—starting with the effects of genes
constitute pathologic conditions or ‘‘natural’’ variations? (2) and hormones early in development on the sexual differen-
How are the criteria for a ‘‘mental disorder,’’ namely ‘‘impair- tiation of the brain—from nonprimate mammals, especially
ment’’ and ‘‘distress,’’ defined for GID? (3) Is psychopathology rodents, but vary to what extent they extrapolate beyond hu
found to be associated with GIV primarily a function of social man gender-related behavior to human gender identity, for
stigma or inherent to the GIV itself? (4) Does the ‘‘mental-dis- which there is no clear animal model at present.
order’’ label by itself serve as an additional source of stigma? (5) As the study of gender development in persons with so-
Is the anatomic accommodation of GID by cross-gender hor- matic DSDs often serves as a bridge from biological animal
mones and surgery really a psychiatric treatment? (6) Finally, research to human investigation, I want to highlight some of
and, from a policy standpoint, most importantly, how can GIV- the dilemmas involved in categorizing GIV as psychopa-
related mental-health and medical services be justified, if ‘‘GID’’ thology with two examples of gender change from the DSD
is removed from the DSM and GIV declared a normal variation? area. Consider the case of a 46,XY child with a severe penile
abnormality due to non-hormonal causes (e.g., penile agen-
esis, cloacal exstrophy of the bladder, or traumatic loss of the
Pathologic Condition versus Natural Variation penis in infancy), who has been raised female, shows strongly
masculinized behavior in childhood, and initiates a change
In general, the demarcation of behaviors that are ‘‘pathologic’’ to the male gender later, as enacted by about a quarter of
from those that are not poses a challenge to the clinician. individuals with such conditions who have been documented
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to date (Meyer-Bahlburg, 2005). What is considered ‘‘path- Some clinicians might question why GIV in persons with
ologic’’ in a case of penile agenesis, for example? Certainly, DSD needs to be considered at all in the context of the dis-
the non-development of a genital tubercle and, later, the ab- cussion of GID and the DSM. There are several reasons: (1)
sence of a penis in an otherwise normal-male developed indi- Despite misgivings among some participants in the respec-
vidual (normal testes, normal androgen production, normal tive work groups at that time, DSM-IV and DSM-IV-TR in-
male reproductive structures, except for the lack of a penis cluded GIV in DSD as GIDNOS, because of similarities in
and the location of the urethral meatus in the rectum), is seen presentation to non-DSD GIVs. (2) In addition, one has to
as pathologic. After early castration and female assignment, note that also in persons with DSD gender identity develop-
such a child shows markedly masculinized (‘‘tomboyish’’) ment is a psychological process, not just an outcome deter-
behavior in comparison to non-DSD girls, but nowadays mined by biological factors. For instance, we have shown
tomboyish behavior is not seen as pathologic. Bisexuality or that 46,XX girls with classical CAH show a dose–response
gynecophilia emerging in adolescence or adulthood is also relationship (on the group level) of prenatal androgens to
not categorized as pathologic, given that homosexuality has gender behavior, but not to (dimensionally assessed) gender
been removed from the DSM. When such a 46,XY person identity (Meyer-Bahlburg et al., 2004), i.e., gender identity is
later initiates gender change to male, it is seen as a ‘‘correc- less closely related to biological factors than gender-related
tion’’ in medical circles outside of psychiatry and similarly by behavior. In fact, gender identity can accommodate wide
lay persons. Yet, in DSM-IV-TR, it is labeled a mental dis- variations in gender-related behavior (Meyer-Bahlburg et al.,
order, namely GIDNOS. On the other hand, if one considers 2006). (3) A number of recent findings suggest that GID may
the gender change to male a ‘‘correction’’ instead of a ‘‘men- perhaps be understood in part as a CNS-limited form of DSD
tal disorder,’’ what about those with the same condition who or intersexuality, without involvement of the reproductive
develop an identity as female and do not change their gender: tract. This is the implication of the demonstration in male-to-
Do they now have to be considered as having a mental dis- female and female-to-male transsexuals of a sex reversal in
order? terms of volume and cell number of sex-dimorphic brain
Another DSD example is provided by 46,XX newborns nuclei, such as the central portion of the bed nucleus of the
with severe degrees of genital masculinization due to clas- stria terminalis (BNSTc; Kruijver et al., 2000; Zhou, Hof-
sical congenital adrenal hyperplasia (CAH) who, when raised man, Gooren, & Swaab, 1995), the interstitial nuclei 3 and 4
female, typically show markedly masculinized behavior la- of the anterior hypothalamus (INAH3 and INAH4; Garcia-
ter; some even initiate gender change to male. In these pa- Falgueras & Swaab, 2008), and the gray matter in the right
tients, many medical features would be considered ‘‘path- (and possibly the left) putamen (Luders et al., 2009), although
ologic’’: the deletion or mutation of the 21-hydroxylase (21- such findings are characterized by large within-group vari-
OH) gene, the resulting deficiency of the 21-OH enzyme, of ability and cross-group overlap. Recently, the neuroanatomic
cortisol and aldosterone, of negative feedback from circu- findings have been complemented by the demonstration of
lating cortisol on ACTH release leading to continuous stim- gender-atypical brain activation patterns in processing ste-
ulation of the adrenal, to adrenal hyperplasia, and to over- roid based odors and erotic stimuli (Berglund, Lindström,
production of adrenal androgens. However, there is less con- Hejne-Helmy, & Savic, 2008; Gizewski et al., 2009).
sensus regarding masculinization of the genitalia. For in- It is also conceivable that there may be genetically based
stance, physicians typically categorize a markedly enlarged systemic sex-hormone abnormalities that do not cause abnor-
clitoris as ‘‘pathologic,’’ but many social constructionists malities of the reproductive anatomy, but nevertheless influ-
emphasize the ‘‘natural’’ variation of peno-clitoral size along ence brain and behavior. This is implied by genetic abnor-
a continuum, which they contrast with the ‘‘socially con- malities (albeit with very modest effect sizes) in terms of
structed’’ binary system of gender (e.g., Fausto-Sterling, increased trinucleotide (CAG) repeats found in the androgen-
2000; Kessler, 1990). Finally, the well established increased receptor (AR) gene of male-to-female transsexuals, which
rate of masculinized gender behavior (Meyer-Bahlburg, are generally associated with impairment of androgen utili-
Dolezal, Baker, Ehrhardt, & New, 2006) and sexual orien- zation (Hare et al., 2009); of an increased prevalence of
tation (Meyer-Bahlburg, Dolezal, Baker, & New, 2008) as CYP17 gene polymorphisms in female-to-male transsexuals
well as the occasional patient-initiated gender change to male associated with higher serum and tissue concentrations of
(Dessens, Slijper, & Drop, 2005; Meyer-Bahlburg et al., both testosterone and estradiol (Bentz et al., 2008), which
1996) in this DSD condition poses questions of categoriza- may explain some hormonal findings reported earlier (Bos-
tion that are very similar to those in 46,XY penile agenesis. inski et al., 1997); and of significant combined partial effects
Thus, in such cases, gender-atypical behaviors that clearly of three polymorphisms in male-to-female transsexualism
‘‘result from the disease processes’’ (Stedman’s Medical Dic- (CAG repeats in the AR gene, tetra nucleotide repeats in the
tionary, 1995) are not necessarily categorized as psychopath- aromatase gene, and CA repeats in the estrogen receptor b
ologic. gene; Henningsson et al., 2005; for new negative findings, see
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466 Arch Sex Behav (2010) 39:461–476
Ujike et al., 2009). Such genetic mechanisms may underlie ment,’’ in parallel to the analogous cases with somatic inter-
the demonstration of substantial heritability of gender-re- sexuality? Again, on the other hand, if patient-initiated gen-
lated behavior in general and GID in particular in child and der change in such GIV cases is a ‘‘correction,’’ a question
adolescent twin samples (Coolidge, Thede, & Young, 2002; arises about the psychiatric status of those cases who develop
Iervolino, Hines, Golombok, Rust, & Plomin, 2005; Knafo, a lasting identification with the assigned gender. The exam-
Iervolino, & Plomin, 2005; van Beijsterveldt, Hudziak, & ples above show that there is no clear scientific solution based
Boomsma, 2006). The absence of genital abnormalities in on etiology alone to the psychiatric categorization of be-
such cases suggests dose specificity or tissue specificity of the havior and identity outcomes of pathological medical con-
androgen receptor deficit, or timing effects, the latter because ditions.
it has long been demonstrated in animal research that the On the basis of some of the biological studies referred to
sexual differentiation of the brain during a hormone-sensitive above, some organizations and quite a few transgender activ-
prenatal or perinatal period can be modified independently of ists have embraced the notion of GIV as firmly biological-
the (earlier) sexual differentiation of the reproductive tract ly grounded (e.g., Gender Identity Research and Education
(Goy, Bercovitch, & McBrair, 1988). The application of highly Society [GIRES], 2006; Winter, 2009). This is clearly pre-
sophisticated new techniques for genome-wide profiling of the mature for several reasons. (1) Leading investigators have
transcriptomes of peripheral blood mononuclear cells, which criticized several of these biological studies on methodo-
led to the demonstration of a discrete set of transcripts direct- logical grounds (e.g., Herbert, 2008). (2) Each of these bio-
ly correlated with XY or XX genotypes independent of male or logical findings is in need of replication by independent,
female genotype of the external genitalia, and another, larger high-quality laboratories. (3) The hypothesis of CNS-limited
gene set that reflected the degree of external genital mas- ‘‘intersexuality’’ as the basis of GID development has most
culinization independent of both sex chromosomes and con- plausibility for the early-onset form of GID with its well estab-
current postnatal sex steroid hormone levels (Holterhus et al., lished cross-gender shift in many gender-related behaviors,
2009), appears to open exciting additional possibilities for including later sexual orientation. It has little plausibility for
genetic approaches to GVs. the explanation of the late-onset form of GID, which in many
One feature of animal models of the sexual differentiation cases seems to develop in the absence of a history of markedly
of brain and behavior that has not yet found sufficient con- gender-atypical behavior of childhood.
sideration in human research on gender development is the Apart from the biological theories of GIV, there are a
observation in rats that males have the neural circuitry of all number of other explanatory models. Updating earlier psy-
aspects of female sexual behavior. That circuitry is usually choanalytic interpretations, several clinician-researchers have
blocked by perinatal sex-hormonal defeminization, but can hypothesized from the perspective of developmental psy-
be activated by the induction of an atypical sex-hormone chopathology that the development of GID is based on pro-
milieu in adulthood (de Vries & Södersten, 2009). Perhaps cesses involving temperamental vulnerabilities and partic-
related mechanisms are involved in the development of such ular patterns of parent–child interaction (Coates, 1990; Di
phenomena as late-onset GID or contribute to the sexual- Ceglie, 1998; Zucker & Bradley, 1995). Others perceive gen-
orientation change observed in many trans persons after onset der transitions in at least some (non-intersex) individuals ‘‘as
of cross-gender hormone treatment (Bockting, Benner, & a solution—a way out of some form of social, psychological,
Coleman, 2009; Lawrence, 2005). or developmental paralysis’’ that is initially unrelated to is-
An alternative biological model that assumes faulty sues of gender (Levine & Solomon, 2009). In yet another
hardwiring (possibly for other than hormonal reasons) of the clinically based theoretical approach, the root of late-onset
gender-specific cortical representation of the genitals as the male-to-female transsexualism is seen in autogynephilia as a
basis of anatomic genital dysphoria in transsexuals was reform of transvestic fetishism (Blanchard, 1989; Lawrence,
cently proposed by Ramachandran and McGeoch (2007), but 2007), also conceptualized as an ‘‘erotic target location er-
fails to explain the broad-band gender-behavior changes seen ror’’ (Freund & Blanchard, 1993; Lawrence, 2009). This
in most individuals with early-onset GIV and requires more theory has led to particularly acerbic controversies, and its
empirical support even for its core assumptions. specificity has recently been questioned by new empirical
Let us assume that in the future one or several of the human data (Moser, 2009; Nuttbrock et al., 2009a).
biological findings above will be shown to be replicable in Self-system theory has led to different psychological mod-
GIV samples by independent, reliable laboratories. Would els. For instance, Doorn, Poortinga, and Verschoor (1994), in
the gender-atypical behavior (including sexual orientation) modifying the theory of Docter (1988), postulated the exis-
in such cases then be considered ‘‘pathologic’’? And what tence of two gender identity subsystems of the self, one
about those who become gender-dysphoric and initiate gen- feminine, the other masculine, which may differ in relative
der change? Would public opinion and government officials strength and may be conditionally or unconditionally ex-
not likely refer to a ‘‘correction of wrong gender assign- pressed. Bockting (2009a) introduced stigma as an additional
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Arch Sex Behav (2010) 39:461–476 467
factor that affects the relative strength of subsystem expres- than, that of ‘‘pathology.’’ Also, some authors (e.g., Langer &
sion. In an extensive study of female-to-male transsexualism, Martin, 2004) have questioned the presence of psychiatric
Devor (1997) developed a detailed process model of trans- dysfunction in individuals with GIV altogether. Moreover,
sexual development, which attributes an important etiologic what defines ‘‘impairment’’ and ‘‘distress’’? DSM-IV and
function to certain family dynamics in the context of a bi- DSM-IV-TR state that the diagnostic features of GID must
gendered patriarchal society. In parallel to the observation I include ‘‘persistent discomfort about one’s assigned sex or a
made earlier in conjunction with the biological intersex sense of inappropriateness in the gender role of that sex.’’ The
model, Devor (1997, p. 67) argued that the psychological text further states:
formation of transsexualism in reaction to unhealthy family
Distress or disability in individuals with GID is mani-
dynamics does not necessarily imply pathology of the result-
fested differently across the life cycle. In young chil-
ing identity.
dren, distress is manifested by the stated unhappiness
One also needs to take into consideration that there are
about their assigned sex. Preoccupation with cross-
types of identity formation other than those related to gender,
gender wishes often interferes with ordinary activities.
such as in people who identify with amputees to the extent
In older children, failure to develop age-appropriate
that they request limb amputation (‘‘Body Integrity Identity
same-sex peer relationships and skills often leads to
Disorder’’; First, 2005; Lawrence, 2006), for which a specific
isolation and distress, and some children may refuse to
biological basis representing a putative natural variation is
attend school because of teasing or pressure to dress in
hard to imagine. Perhaps it can be better understood as a form
attire stereotypical of their assigned sex. In adolescents
of identity development that Wilkinson-Ryan and Westen
and adults, preoccupation with cross-gender wishes
(2000) have described as ‘‘role absorption’’ in patients with
often interferes with ordinary activities. Relationship
borderline personality disorder. A similar new case report
difficulties are common, and functioning at school or at
documents the co-occurrence of a desire for a non-mutilative
work may be impaired.’’(American Psychiatric Asso-
disability with transsexualism (Kolla & Zucker, 2009). In any
ciation, 2000, p. 577)
case, it is difficult to justify the term ‘‘natural’’ variation for a
condition that compels the respective individual to severely As a clinician working with such children, I see several
alter a healthy body by gonadectomy with attendant infer- problems with this paragraph (all of which are in need of more
tility and the replacement of intact primary and secondary sex systematic empirical documentation). (1) When one takes the
characteristics with those of the other gender. developmental history of preschool children with GID, the
At this stage of our knowledge, none of the proposed initial features are not gender dysphoria, but gender-atypical
theories of gender development are sufficiently empirically temperament and activity preferences, and, in many boys,
validated to permit firm conclusions regarding the delinea- unusual sensory sensitivities (Coates & Wolfe, 1995). (2) In
tion of psychopathologic from normal processes. In partic- non-GID children, ‘‘preoccupation’’ is not limited to gen-
ular, the conceptualization of GIV as a fully biologically dered activities. For instance, DeLoache, Simcock, and
based identity that is accidentally embedded in a body of Macari (2007) found ‘‘extremely intense interests’’ in nearly
incongruent sex is not easy to ground in empirical evidence a third of a sample of 84 boys and 93 girls (aged 11 months
(see also Blanchard, 2008). Also, it seems entirely conceiv- to 6 years of age) from predominantly white middle class
able that there are more pathways to GIV than one. Perhaps families in the U.S., with a boy:girl ratio of 3:1. (3) In young
the solution of this issue has to await the application of children with GIV, gender ‘‘dysphoria’’ appears to develop
computational models of normal and dysfunctional brain when the cognitive development is far enough advanced and
operations within theoretical neuroscience to the sexual if the gender-atypical inclinations are criticized and opposed
differentiation of brain and behavior (Thagard, 2008). by the parents and others. (4) Gender segregation in the peer
group is normative in childhood and not labeled ‘‘impair-
Impairment and Distress ment’’ if it is gender-typical. Is it not appropriate for a highly
gender-atypical child to affiliate with the peer group that is
In the development of DSM-III, ‘‘impairment’’ and/or ‘‘dis- more compatible with his or her gender behavior, especially
tress’’ became the primary criteria for the categorization of if it also offers more acceptance (as shown by Wallien,
a behavioral condition as a ‘‘mental disorder.’’ This is ech- Veenstra, Kreukels, & Cohen-Kettenis, 2009)? (5) Many
oed in a paper by Wakefield and First (2003) who suggested later problems (e.g., school refusal) appear to be secondary to
that ‘‘GID’’ without ‘‘impairment’’ or ‘‘distress’’ should just the child’s experience of stigmatization of the gender-atyp-
be classified as a ‘‘dysfunction,’’ which attains status as a ical behavior. (6) In the general population, individuals vary
‘‘mental disorder’’ only when combined with ‘‘impairment’’ considerably in stress responsivity and emotional coping,
and/or ‘‘distress.’’ It seems to me, however, that the definition and, in my clinical work, I am impressed by a similar vari-
of ‘‘dysfunction’’ is the same as, and not less problematic ability of individuals meeting criteria for GID or GIDNOS.
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There also seems to be considerable intraindividual vari- the rates of psychiatric problems after assignment to the de-
ability in gender-related distress over time. I am, therefore, sired gender diminish (Murad et al., 2009; Pfäfflin & Junge,
not convinced that—in the absence of systematic documen- 1998). Moreover, much of psychiatric distress and suicidality
tation of distress—it is appropriate to routinely attribute seen in transgender persons can be statistically accounted for
‘‘inherent distress’’ to all who want to change gender (Zucker, by the effects of stigmatization itself (Nuttbrock et al., 2009b)
2006). If one postulates ‘‘inherent distress,’’ would one not and is therefore not necessarily inherent in persons with GID.
also have to attribute something like ‘‘body dysphoria’’ to On the other hand, other psychiatric diagnoses, such as PTSD,
patients with somatic diseases or disorders who decide for are validly made as attributes of individuals, although their
surgery (say, of a facial wart) or radiation treatment (of can- origin has been an external event or chronic stressful situation.
cer) and thereby label them as having a ‘‘mental disorder’’? One has to realize, of course, that even if GID is associated with
On the other hand, limiting the disorder category of GIV to increased risk of other psychopathology, its definition as a
those with marked distress would imply the exclusion from mental disorder should stand on its own feet and not rely on
medical assistance of those without. ‘‘co-morbidity’’ (in itself a term that implies GID as ‘‘morbid-
ity’’).
GIV-associated Psychopathology
The Label of ‘‘Mental Disorder’’ as a Source of Added
By definition, persons with the more marked degrees of GIVs Stigma
are included in the DSM, because of the assumption that their
condition includes clinically significant distress and/or im- The label, ‘‘mental disorder,’’ can be stigmatizing, as is well
pairment. In fact, McHugh (2004) noted as one of the main documented (e.g., Link & Phelan, 2001; Winter, 2009), and
arguments for closing the Hopkins clinic in 1979 (when he psychiatric nomenclature changes have repeatedly been made
was chair of the respective psychiatry department) that de- in order to diminish the stigmatization associated with certain
spite undergoing SRS, which few later regretted, the patients well-established categories. Transgender advocates have cited
‘‘had much the same problems with relationships, work, and examples of the use of the categorization of transgenderism as
emotions as before.’’ McHugh concluded that ‘‘human sexual a mental illness to the detriment of transgender persons in child
identity is mostly built into our constitution by the genes we custody disputes, employment, access to security clearances,
inherit and the embryogenesis we undergo…. Sexual dys- marriage continuation, serving in the military, receiving men-
phoria…can be socially induced in apparently constitution- tal or physical health services, and establishing policies for
ally normal males, in association with (and presumably civil-rights protection (Vance et al., 2009). Winter et al. (2009)
prompted by) serious behavioral aberrations.’’ Thus, for him, conducted a world-spanning seven-country study of transpre-
providing psychiatric and medical assistance towards SRS judice directed at ‘‘transwomen’’ (male-to-female transsexu-
was ‘‘collaborating with madness.’’ (Note, however, that als) using a 30-item questionnaire and non-orthogonal factor
McHugh’s etiologic formulations are not based on solid analysis. The by far largest factor, which accounted for 30% of
empirical evidence, and that the pessimistic evaluation of the total variance, included some items with clear references to
SRS outcome is not shared by follow-up studies.) mental illness (e.g., ‘‘Transwomen…’’ ‘‘1. are men with some-
In the developments leading up to the removal of homo- thing wrong in their mind’’, ‘‘4. are mentally disordered’’) and
sexuality from the DSM, the demonstration that there were others that could be—somewhat loosely—so interpreted (e.g.,
homosexuals who led productive and satisfied lives without ‘‘7. are sexual perverts’’, ‘‘17. have unstable personalities’’)
demonstrable psychopathology constituted an important and was, therefore, labeled ‘‘Mental Illness.’’ Participants
argument against the notion of homosexuality as a pervasive viewing transwomen as mentally ill tended to avoid any form
mental disorder. Although significant associated psychopa- of contact with them, as well as to deny them the status or rights
thology has been seen in both DSD (Schützmann, Brink- of women. Winter et al. used their findings as a strong argu-
mann, Schacht, & Richter-Appelt, 2009) and non-DSD ment for removing GIVs from the psychiatric nomenclature.
gender-dysphoric persons (Clements-Nolle, Marx, & Katz, Of course, there is always the question how much of social
2006; Levine & Solomon, 2009; Nuttbrock et al., 2009a), this stigma is associated with the observable gender atypicality
is by no means universal. It is often not seen in young children rather than the psychiatric label by itself. In addition, some
with GID (Zucker & Bradley, 1995), and not in all adoles- explicit categorization of people with conditions that require
cents and adults with GID before they undergo hormonal and therapeutic intervention is necessary as a prerequisite of clin-
surgical measures associated with gender reassignment ical and scientific communication. Some transgender advo-
(Cohen-Kettenis & van Goozen, 1997; Smith, van Goozen, & cates also cite prospective benefits other than insurance cov-
Cohen-Kettenis, 2001; Smith, van Goozen, Kuiper, & Co- erage for mental and physical health services from retaining
hen-Kettenis, 2005; Wallien & Cohen-Kettenis, 2008), and the psychiatric categorization: preventing misdiagnosis of
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Arch Sex Behav (2010) 39:461–476 469
transgender individuals with other mental illness categories; more likely to be transient (Borras, Huguelet, & Eytan, 2007).
facilitating acceptance of the person’s gender identity by Moreover, the economic problems caused by the escalating
family and employers; legitimizing the condition; guiding costs of health care in general will increasingly require jus-
research; and furthering the development of transgender ser- tifications of expensive and chronic medical treatments and
vices (Vance et al., 2009). At the same time, strong anti- set limits to service provisions on demand. One also has to
discrimination efforts by organizations such as the National take into consideration the widespread existence of stigma
Alliance on Mental Illness are showing increasing success. and violence against transgender persons that makes legal
Thus, the cost–benefit ratio of a psychiatric label may grad- protections desirable.
ually shift towards the benefit side. What would happen if GID was removed from the DSM?
According to Franklin Romeo, JD, of the Sylvia Rivera Law
Project, a nonprofit organization providing legal services for
Psychiatric Treatment Versus Anatomic
transgender persons (http://www.srlp.org), the DSM status
Accommodation
of ‘‘GID’’ is crucial in legal proceedings concerning access
of people with GID to health care and in sex-discrimination
Usually, psychiatric treatment focuses on the reduction of
claims, especially disability discrimination claims (Romeo,
psychological symptoms. Psychiatric treatment of GID would,
2008; see also Currah, Juang, & Minter, 2006). In Romeo’s
therefore, imply the reduction of the cross-gender identifica-
view, the removal of GID from DSM would have ‘‘cata-
tion and the same-gender dysphoria. Yet, treating GID ado-
strophic’’ consequences for the legal settlements of such
lescents with puberty-suppressing medications, and treating
cases. In this context, one needs to remember that human
GID adults with cross-gender hormones and genital surgery,
rights approaches and medical pathology classifications can
and thereby inducing hypogonadism and infertility (reversible
coexist as illustrated by current disability-protection regu-
when done by GnRH analog treatment in the adolescent, ir-
lations. Note the admonition by Levine and Solomon (2009)
reversible when done by gonadectomy in the adult), means
that ‘‘emphasis on civil rights is not a substitute for the rec-
modifying the somatic pubertal development and the con-
ognition and treatment of associated psychopathology.’’
genital body anatomy in order to accommodate, ‘‘confirm,’’ or
‘‘affirm’’ the atypical identity (Hembree et al., 2009). The key
symptom of atypical gender identity is also supported, when a
young child is sent to school in the desired gender, with a
Options for GIVs in DSM-V
corresponding gender-specific name, haircut, and clothing, as
has happened with a number of recent cases in the U.S. (e.g.,
Several options need to be considered for the DSM revision:
Cloud, 2000; see also Brill & Pepper, 2008, pp. 153–192).
(1) Retaining the ‘‘GID’’ label; (2) narrowing the psychiatric
Within psychiatry, these are certainly unusual treatment ap-
categorization of GIVs and changing the label; (3) declaring
proaches, as has been noted by others (e.g., Federoff, 2000;
GIVs non-psychiatric medical conditions (e.g., neurologic
McHugh, 2004). If the treatment is not really ‘‘psychiatric,’’
disorders); (4) removing GIVs from both DSM and ICD; and
can the categorization of GID as a mental disorder be main-
(5) removing GIVs from the Axis-I psychiatric disorders and
tained? Or should the psychiatric disorder be reconceptualized
creating a special DSM category.
and cross-gender identity be removed from the criteria? At the
very least, GID is an unusual psychiatric category, in that it is
based on an incongruence between the assigned gender (usu-
Retaining the ‘‘GID’’ Label
ally based on the genital appearance) and the experienced
gender, and the most successful intervention to date for adults in
Retaining GIVs under the term, ‘‘GID,’’ as Axis-I psychiatric
terms of patient satisfaction appears to be hormonal and surgical
disorders, probably with some modification of the criteria and
body modification.
text (see the papers by Zucker, 2009 and by Cohen-Kettenis
and Pfäfflin, 2009) would have the advantage of not endan-
Justification of Treatment if GID is not a Disorder gering the insurance coverage, where it exists, of psychiatric
and medical procedures that are used in the evaluation and
Regardless of its categorization as mental disorder or not, treatment of persons with GIVs, and of not placing at risk
GID in childhood requires mental health evaluation and legal disability protections where applicable. However, such
counseling, and GID in adolescence and adulthood requires a decision would imply labeling GIV individuals without
both along with medical services. For instance, no service overt, significant distress and/or impairment and without
provider would want to have individuals go through gender associated psychopathology as mentally ill. It would also
re-assignment and/or medical treatment whose GIV is ex- have the potential consequence of (at least indirectly) sup-
pressed in the context of a severe psychosis and therefore porting and justifying GIV-discriminatory sentiments in the
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470 Arch Sex Behav (2010) 39:461–476
population at large. Finally, the decision would not be helpful Separating GID from sexuality issues and making it a free-
for the relationship between mental-health service providers standing category of its own is advocated by some. However,
and the transgender communities. that solution would run counter to the intent of the DSM to
If GID is retained in the DSM, where should it be placed? create meaningful groupings of psychiatric diagnoses, if such
Several arguments speak for retaining the supraordinate can be found.
category ‘‘Sexual and Gender Identity Disorders.’’ Evalua-
tion and counseling for sexual issues play a significant role for
many adolescent and adult patients both in regard to sexual Narrowing the Psychiatric Categorization
orientation and the impact of gender change on ongoing
romantic, sexual, or marital partnerships. Moreover, sexual One way of diminishing the psychiatric stigma potential of
functioning may be markedly affected—positively as well as the diagnostic term ‘‘GID’’ would be the limitation of the
negatively—by gonadectomy, hormone treatment, and gen- psychiatric diagnosis to those who are distressed about living
ital surgery. There is also the (highly controversial) issue of with a gender assignment they experience as incongruent
the role of transvestic fetishism in the development of late- with their sense of self and to change the term to ‘‘gender
onset GIV (which for some transgender advocates provides a dysphoria’’ or ‘‘gender dissonance’’ (Bockting, 2009b; Lev,
strong motive for moving GIV away from a supraordinate 2005; Winters, 2005), i.e., remove the ‘‘disorder’’ label (pref-
category involving any paraphilias; see de Cuypere et al., erably also from the supraordinate category). Thus, gender-
2009). Thus, clinicians dealing with adolescents and adults related dysphoria would now become the major criterium of
with GID should be trained and experienced sufficiently to the diagnosis, and the identity criterium removed, which
deal with both the gender and the sexual aspects of their would address one of the major complaints by many in the
patients’ lives, which would be facilitated by retaining the transgender communities. The term would not apply to per-
combined supraordinate category. However, the explicit sons who have undergone gender change and are now satis-
‘‘disorder’’ term of the supraordinate category would poten- fied with their new gender, unless it is combined with some
tially contribute to psychiatric stigmatization, and a respec- specification such as ‘‘in remission,’’ which is needed to
tive modification of the grouping label should therefore also justify continued medical and mental-health services (Bock-
be considered. ting & Ehrbar, 2005). It would also not apply to children
To emphasize communalities of body-focused identity engaging in extensive cross-gender activities or even living
issues in various conditions, one could consider grouping in the desired gender without symptoms of gender dysphoria
‘‘GID’’ together with other psychiatric syndromes that focus (although they could be considered at risk of gender dys-
on body-related aspects of identity, with which GIV has at phoria if pressure towards social conformity should increase
least superficial similarity. For instance, in Body Integrity in their social environment). One task force suggested the
Identity Disorder (First, 2005), patient satisfaction is based term ‘‘gender discordance’’ for adults with GIV who do not
on the removal of a limb and, thereby, acquisition of the status repudiate their congenital somatic sex characteristics (Wash-
of visible body impairment. Patients with Anorexia Nervosa ington Psychiatric Society, 2009); in contrast to DSM-IV-
aim at achieving extreme degrees of body thinness. Patients TR, this group also recommended to include distress in re-
with Body Dysmorphic Disorder are focused on imagined or sponse to social stigma in the diagnostic criteria. Another
exaggerated defects in the appearance of their body (Amer- way of narrowing the diagnosis had been proposed by Rich-
ican Psychiatric Association, 2000). And, finally, there are ardson (1999), who, in the case of children, wanted to limit
people who pursue castration (without medical indication) the diagnosis to those who employed cross-gendered inter-
for a variety of reasons, for instance, for gender change to ests ‘‘in a pathological way’’: ‘‘Cross-dressing or cross-gen-
‘‘neither male nor female’’ (Male-to-Eunuch GID) or to re- der play could be required to be joyless, compulsive, fraught
duce libido (Brett, Roberts, Johnson, & Wassersug, 2007; with rage or anxiety, or frankly dissociative to qualify for
Johnson, Brett, Roberts, & Wassersug, 2007; Money, Job- inclusion.’’ The existence of such children, however, is yet to
aris, & Furth, 1977; Wassersug & Johnson, 2007). Such a be documented. In either case, the narrowing of the diag-
grouping might facilitate the exchange between profession- nostic term would meet some of the major criticisms of the
als specializing separately on these individual syndromes current ‘‘GID’’ diagnosis. Yet, it would disadvantage indi-
and, thereby, foster comparative research, lead to new in- viduals who seek medical treatments in the absence of sig-
sights into identity development, and help formulate new nificant distress or associated psychopathology and possibly
treatment approaches. A drawback, however, would be the even those parents who seek help from mental-health spe-
relative neglect of sexual aspects of the GIV conditions. cialists in dealing with their GIV children.
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Arch Sex Behav (2010) 39:461–476 471
Declaring GIV a Neurologic or Medical Disorder rate of desisters from a long-term transgender development is
higher in young children than in adults, the difference is only a
Another recurrent suggestion on how to address the issue of matter of degree and diminishes with age. The expanding use of
label-related psychiatric stigma is to change ‘‘GID’’ from a puberty-blocking agents in the clinical management of young
psychiatric to a neurologic or neurocognitive disorder. This is adolescents with GID also requires some justification in terms of
supported by the gradually accumulating findings from brain an illness or disorder model.
imaging and neuroanatomic studies that suggest a neuro-
anatomic basis of GIV development (see references listed Creating a Special Category for GIVs
earlier). However, on the one hand, hardly any of the scat-
tered findings have been replicated to date, and their func- As outlined earlier, ‘‘GID’’ as a psychiatric condition is un-
tional implications are not yet understood; thus, the evidence ique. We do not have clear criteria to differentiate normal
base is still insufficient. On the other hand, given the ongoing from pathologic identity developments, the distress/impair-
rapid advances in the neurosciences, the demarcation of ment criteria do not seem to apply universally, the prevalent
‘‘psychiatric’’ from ‘‘neurologic’’ becomes an issue through- treatment of ‘‘GID’’ in adulthood consists of the hormonal
out psychiatry and neurology, and a solution of this issue for and surgical alteration of a healthy body, and mental-health
one isolated category such as ‘‘GID’’ rather than for the two specialists are needed for diagnostic screening, adjustment
fields overall in a systematic manner seems inappropriate. guidance, and dealing with the effects of social stigma. This
The related suggestion of removing GIVs from the DSM constellation of problems appears to require breaking the
and relabeling them ‘‘medical conditions’’ (e.g., Lev, 2005) Procrustean bed of the current DSM classification system.
runs into two major problems. One is that, in non-DSD GIVs, I suggest, therefore, that the special status of the GIV
the reproductive tract and body as a whole appear healthy, the condition be recognized by using a clear descriptive term,
other that neither endocrinologists nor surgeons are trained to ‘‘gender incongruence’’ (already used in the text of DSM-III-
provide the diverse mental-health services needed and sought R), now defined as ‘‘the incongruence of one’s gender ex-
by many individuals with GIV and their families. Referral to perience and expression with one’s assigned gender and,
such mental-health services would often run into problems of where applicable, one’s congenital primary and secondary
insurance coverage, and the availability of respective spe- sex characteristics.’’ Thus, distress or impairment would not
cialists diminish further, when there is no representation of be a necessary part of the categorization. Instead, it should be
GIV-related problems in the DSM. graded as a specifier dimension, along with the experience
and anticipation of stigmatization, if any, and the addition-
Removing GIV from Both DSM and ICD al specifier ‘‘post-transition’’ where applicable. Individuals
with Gender Incongruence associated with a somatic DSD
Finally, many persons with GIVs and activists advocate the could be classified as a subtype. The Gender Incongruence
removal of GIVs from both the psychiatric and medical text would explain the unusual status of the GIV condition
‘‘disorder’’/‘‘disease’’ nomenclature, in analogy to the fate of between psychiatry and non-psychiatric medicine in need of
the homosexuality label in the 1970s and to phenomena such specialized mental-health and medical services, but not
as ‘‘left-handedness’’ or ‘‘non-righthandedness,’’ which never classify it as a psychiatric disorder per se. This formulation
entered the DSM or ICD systems. For instance, Pickstone- will probably reduce the stigma potential of the label. On the
Taylor (2003) recommended the term ‘‘gender nonconfor- other hand, the retention of a special category for GIV in the
mity’’ to indicate that GIV does not constitute psychopathol- DSM will make it more likely that health and mental-health
ogy. Obviously, this would preclude insurance coverage for service providers identify children with GIV early, which
treatment procedures under current regulations in many coun- then provides opportunities for early needs assessment and
tries and even potentially jeopardize legal protections under access to care including transpositive, i.e., cross-gender
disability regulations. supportive approaches (Bockting & Ehrbar, 2005; Cohen-
Some authors have recommended to remove GIV for chil- Kettenis, 2001), and that anti-discrimination efforts continue
dren from both DSM and ICD, but leave GIV for adults in the to be supported. If the overall DSM-IV structure should be
DSM, possibly with significant modifications. This approach carried over into DSM-V, ‘‘Gender Incongruence’’ would
has recently been implemented by the Swedish government for have to be placed under ‘‘Other Conditions that May be a
the Swedish version of the ICD-10 in order to reduce stigma- Focus of Clinical Attention,’’ but its insurance coverage
tization, while ‘‘transsexualism’’ has been retained because of would need to be explicitly backed by respective declarations
the need for medical procedures in the course of gender reas- of professional organizations such as the American Medical
signment (International Foundation for Gender Education, 2008). Association and the American Psychiatric Association. It
This splitting of child and adolescent/adult GIVs does not seem would be preferable, therefore, if DSM-V either redefined
warranted on both scientific and clinical grounds. Although the this section, or create a new section formulated so that it
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472 Arch Sex Behav (2010) 39:461–476
would facilitate the insurance coverage needed. (One sug- and forth between their desired and their natal gender, indi-
gestion from the WPATH consensus group [de Cuypere et al., viduals for whom the pursuit of gender change appears to be a
2009] was the relocation of the GIV category to a potential way out of other (non-gender based) problems, and individuals
new supraordinate category for DSM entitled ‘‘Psychiatric where GIV is just secondary to a psychotic process, specific
conditions related to a medical condition,’’ but, as argued subthreshold or ‘‘NOS’’ terms should be defined.
earlier, the justification for a ‘‘medical condition’’ is prob- It is clear that the decision on the DSM- or ICD-catego-
lematic.) rization of GIVs cannot be achieved on a purely scientific
basis. Instead, scientific issues need to be considered in com-
bination with the service needs of persons with GIVs and the
Conclusions psychosocial implications of DSM formulations for such
persons, when one works towards a consensus among stake-
GVs fall onto a spectrum or continuum ranging from mild holders regarding a pragmatic compromise.
presentations such as gender-atypical behavior (e.g., ‘‘tom-
boyish’’ behavior of girls) without effect on core gender Acknowledgments Brief, preliminary versions of this paper were
presented at the Annual Meeting of the American Academy of Child and
identity through presentations of clinical relevance such as, Adolescent Psychiatry in Chicago, IL, October 28–November 2, 2008,
in males, the repudiation of certain anatomic and physio- and the Annual Meeting of the Society for Sex Therapy and Research in
logical features of manhood without the desire for changing Arlington, VA, April 2–5, 2009. The draft of this paper benefitted from
into a female (e.g., Male-to-Eunuch GID; Wassersug & discussions among, and direct feedback from, the members of the GID
Subworkgroup (Peggy T. Cohen-Kettenis, Jack Drescher, Friedemann
Johnson, 2007), to the desire for full gender transition in- Pfäfflin, Kenneth J. Zucker, and the author) of the Sexual and Gender
cluding the acquisition of the somatic characteristics of the Identity Disorders Work Group for DSM-V of the American Psychiatric
other gender. Characteristic of the entire spectrum is behav- Association, and from Jamison Green as Work Group Advisor. Al-
ioral or psychological gender atypicality relative to the sta- though the author is a member of this APA Work Group, this paper does
not represent the position of the Work Group or the APA, but the author’s
tistical norm, which can be readily quantified as a behavioral own perspective. Patricia Connolly assisted in bibliographic work and in
dimension. The more extreme cases are GIVs, that is, they word processing. This work was supported, in part, by NIMH grant P30-
show incongruence between their assigned gender with its MH-43530 (P.I.: Anke A. Ehrhardt, Ph.D.). Reprinted with permission
associated societal role expectations on the one hand and from the Diagnostic and Statistical Manual of Mental Disorders V
Workgroup Reports (Copyright 2009), American Psychiatric Asso-
their subjective experience of gender identity and the association.
ciated desire for gender expression on the other. In the ab-
sence of an empirically grounded detailed theory of the mech-
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DOI 10.1007/s10508-009-9540-4
ORIGINAL PAPER
The DSM Diagnostic Criteria for Gender Identity Disorder

in Children
Kenneth J. Zucker

Abstract In this article, I review the diagnostic criteria for Association, 1980). In DSM-III, there were three relevant
Gender Identity Disorder (GID) in children as they were for- diagnostic entities: Gender Identity Disorder of Childhood
mulated in the DSM-III, DSM-III-R, and DSM-IV. The article (GIDC), Transsexualism (for adolescents and adults), and
focuses on the cumulative evidence for diagnostic reliability Psychosexual Disorder Not Elsewhere Classified. The last
and validity. It does not address the broader conceptual dis- category was a residual diagnosis, ‘‘for disorders whose chief
cussion regarding GID as ‘‘disorder,’’ as this issue is addressed manifestations are psychological disturbances not covered by
in a companion article by Meyer-Bahlburg (2009). This article any of the other specific categories in the diagnostic class of
addresses criticisms of the GID criteria for children which, in Psychosexual Disorders’’ (American Psychiatric Association,
my view, can be addressed by extant empirical data. Based in 1980, pp. 282–283). One example pertained to ‘‘marked feel-
part on reanalysis of data, I conclude that the persistent desire ings of inadequacy related to self-imposed standards of mas-
to be of the other gender should, in contrast to DSM-IV, be a culinity or femininity…’’ (p. 283). In DSM-III-R (American
necessary symptom for the diagnosis. If anything, this would Psychiatric Association, 1987), there were four relevant diag-
result in a tightening of the diagnostic criteria and may result in nostic entities: GIDC, Transsexualism, Gender Identity Dis-
a better separation of children with GID from children who order of Adolescence or Adulthood, Nontranssexual Type
display marked gender variance, but without the desire to be of (GIDAANT), and Gender Identity Disorder Not Otherwise
the other gender. Specified (GIDNOS). The last category was a residual diag-
nosis and four examples were provided: (1) children with
Keywords Gender Identity Disorder Children DSM-V persistent cross-dressing without the other criteria for GIDC;
(2) adults with transient, stress-related cross-dressing behav-
ior; (3) adults with the clinical features of Transsexualism of
less than 2 years’ duration; and (4) people who have a persis-
…no one should mistake expert consensus for the truth tent preoccupation with castration or peotomy without a desire
(Hyman, 2003) to acquire the sex characteristics of the other sex (American
Psychiatric Association, 1987, p. 78). In DSM-IV and DSM-
IV-TR (American Psychiatric Association, 1994, 2000), there
Introduction were three relevant diagnostic entities: Gender Identity Dis-
order (GID) (with separate criteria sets for children versus
Gender Identity Disorders entered the DSM nosological sys- adolescents/adults), Transvestic Fetishism (with Gender Dys-
tem with the publication of DSM-III (American Psychiatric phoria), and GIDNOS. The last category was a residual and
three examples were provided: (1) intersex conditions with
‘‘accompanying gender dysphoria’’ (p. 582); (2) transient,
K. J. Zucker (&) stress-related cross-dressing behavior; and (3) persistent pre-
Gender Identity Service, Child, Youth, and Family Program,
occupation with castration or penectomy without a desire
Centre for Addiction and Mental Health, 250 College Street,
Toronto, ON M5T 1R8, Canada to acquire the sex characteristics of the other sex. In DSM-IV,
e-mail: [email protected] the previous categories of GIDC and Transsexualism were
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478 Arch Sex Behav (2010) 39:477–498
collapsed into one overarching diagnosis, GID, which had, Table 1 DSM-III diagnostic criteria for Gender Identity Disorder of
as noted above, distinct criteria sets for children versus ado- Childhood
lescent and adults. On the recommendation of the DSM-IV For females
Subcommittee on Gender Identity Disorders (Bradley et al., A. Strongly and persistently stated desire to be a boy, or insistence that
1991), elements of the GIDAANT diagnosis were also incor- she is a boy (not merely a desire for any perceived cultural advantages
porated into the DSM-IV criteria for GID for adolescents and from being a boy)
adults. B. Persistent repudiation of female anatomic structures, as manifested
by at least one of the following repeated assertions
Over these three editions of the DSM, the Gender Identity
(1) that she will grow up to become a man (not merely in role)
Disorders have had different placements in the manual: in
(2) that she is biologically unable to become pregnant
DSM-III, the diagnoses were in the section called Psychosexual
Disorders; in DSM-III-R, the diagnoses were in the section (3) that she will not develop breasts
called Disorders Usually First Evident in Infancy, Childhood, or (4) that she has no vagina
Adolescence; and, in DSM-IV, the diagnoses were in the section (5) that she has, or will grow, a penis
called Sexual and Gender Identity Disorders. C. Onset of the disturbance before puberty (For adults and adolescents,
see Atypical Gender Identity Disorder.)
This review paper will focus on the GID diagnostic criteria
For males
for children. It will examine the evolution of the criteria sets,
A. Strongly and persistently stated desire to be a girl, or insistence that he
evidence for their reliability and validity, criticisms of the cur- is a girl
rent criteria, and then proposed options for reform of the criteria.
B. Either (1) or (2)
In this review, I will not comment on the DSM-IV-TR GIDNOS
(1) persistent repudiation of male anatomic structures, as manifested
diagnosis (or its predecessors in DSM-III and DSM-III-R), as by at least one of the following repeated assertions
this category will be discussed and considered by the entire (a) that he will grow up to become a woman (not merely in role)
Gender Identity Disorders subworkgroup. When I discuss be- (b) that his penis and testes are disgusting or will disappear
low children who are subthreshold for the GID diagnosis, this is (c) that it would be better not to have a penis or testes
not meant to imply that they would meet criteria for GIDNOS as (2) preoccupation with female stereotypical activities as manifested by
it is has been formulated in the various editions of the DSM. The a preference for either cross-dressing or simulating female attire, or
term ‘‘subthreshold’’ simply means that the child was not judged by a compelling desire to participate in the games and pastimes of
to meet the complete diagnostic criteria for GID. girls
C. Onset of the disturbance before puberty. (For adults and adolescents,
see Atypical Gender Identity Disorder.)
Review of the Diagnostic Criteria (DSM-III,

DSM-III-R, and DSM-IV) For the Point B criterion for girls, there was only one crite-
rion: persistent repudiation of female anatomic structures (in-
DSM-III ferred from at least one of five indicators). For boys, there was an
analogous persistent repudiation of male anatomic structures
Table 1 shows the DSM-III diagnostic criteria for GIDC. It (inferred from at least one of three indicators), but there was a
should be noted that the criteria were somewhat different for second criterion that could also be used. This criterion pertained
females versus males (girls versus boys), a tradition that has to a ‘‘preoccupation with female stereotypical activities’’ (as
continued through the DSM-IV and DSM-IV-TR. Although manifested by at least one of two behavioral indicators) or by
beyond the scope of this review, that the DSM has specified a ‘‘compelling desire’’ to participate in cross-gender activities.
somewhat different criteria for boys versus girls is of interest in For girls, then, GIDC was diagnosed based on two criteria: a
its own right, as there are very few DSM diagnoses that have persistent wish to be of the other sex and by the persistent
sex-specific criteria. Some authors have, however, argued that negation of one’s sexual anatomy. For boys, GIDC was diag-
they might be necessary for some conditions, such as Conduct nosed based on a minimum of two criteria: a persistent wish to
Disorder (CD) (see, e.g., Crick & Zahn-Waxler, 2003; Zahn- be of the other sex and by the persistent negation of one’s sexual
Waxler, 1993; Zoccolillo, 1993; for a general overview, see anatomy or some manifestation of pervasive cross-gender role
Widiger, 2007; Widiger & First, 2007). preferences/desires.
For the Point A criterion, both girls and boys were re-
quired to have a ‘‘strongly and persistently stated desire’’ to be Comment and Critique
of the other sex or to verbalize the ‘‘insistence’’ that one was a
member of the other sex; for girls, there was the additional The criteria were formulated by a panel of experts, i.e., by at
proviso that such a desire was not due to a perceived cultural least some members of the Psychosexual Disorders Advisory
advantage from being a boy. No such proviso was required for Committee who had clinical and research experience with this
boys. population (e.g., Green, 1974; Stoller, 1968). The criteria were
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Arch Sex Behav (2010) 39:477–498 479
not subject to any formal field trials for the purpose of estab- Although not intended to be exhaustive, I will provide a
lishing diagnostic reliability or validity. couple of examples from the DSM-III era. In Green’s (1974,
Various descriptors in the criteria (‘‘strongly,’’ ‘‘persistent/ 1976, 1987) study of feminine boys and a control group of boys
persistently,’’ ‘‘insistence,’’ ‘‘preoccupation,’’ and ‘‘compelling unselected for their degree of masculinity-femininity (both
desire’’) were all presumably used to differentiate children with groups were recruited via advertisement), an array of questions
potential gender identity problems from children who might, on (item analysis) answered by parents was used to test for sig-
a transitory or infrequent basis, verbalize a desire to be of the nificant between-groups differences. Using parent-interview
other sex or engage in cross-gender behavior (B2 for boys) (see, data, Green (1987) reported a discriminant function analysis in
e.g., Linday, 1994). This point was also emphasized in the text which 6 of 16 sex-typed behaviors (e.g., cross-dressing, wish to
portion of the DSM-III (American Psychiatric Association, be a girl, etc.) were able to classify correctly all boys as members
1980, pp. 264–265). Because the criteria for girls required the of either the feminine group or the control group (see also
presence of ‘‘anatomic dysphoria’’ (Criterion B), but the criteria Roberts, Green, Williams, & Goodman, 1987).
for boys did not (Criterion B2 was sufficient for this criterion), it In DSM-III, one of the criteria for boys pertained to ‘‘a
could be argued that the criteria for girls were more conservative compelling desire to participate in the games and pastimes of
than they were for boys (for a historical documentation of this girls.’’ Zucker, Doering, Bradley, and Finegan (1982) reported
point using unpublished archival material, see Bryant, 2007). on the free play behavior of gender-referred children compared
In an early critique of the DSM-III criteria, Zucker (1982) to that of their siblings and clinical controls on a 3-trial task in
argued that Criterion B for girls was, perhaps, overly stringent a ‘‘laboratory-like’’ situation. On Trial 1 (5 min), the children
in that there was a strong emphasis on immature, if not ‘‘de- were exposed to stereotypical masculine and feminine toys; on
lusional,’’ statements (e.g., that ‘‘she has no vagina,’’ ‘‘that she Trial 2 (5 min), they were exposed to stereotypical masculine
has…a penis’’). There was less of an emphasis on feelings of and feminine dress-up apparel; and on Trial 3 (10 min), they
anatomic dysphoria or ‘‘fantasies’’ of having the sexual anatomy were exposed to both sets of stimuli simultaneously. On all
of the other sex (e.g., that one would, on a frequent basis, like to three trials, the gender-referred children played significantly
have a penis). longer with the cross-sex stimuli than did the two control groups.
Zucker (2005a) subsequently reported, using a conservative
Reliability and Validity method, the effect sizes for this comparative analysis: the effect
sizes ranged from 0.78 to 1.36.1
Zucker, Finegan, Doering, and Bradley (1984) conducted the In a subsequent study, Zucker et al. (1984) provided addi-
only study that attempted to establish the reliability of the tional comparative analysis using several measures of sex-typed
DSM-III GIDC criteria in terms of agreement between two behavior by comparing gender-referred children who were
raters. From chart information reported by parents of gender- judged by a clinician to meet the complete DSM-III criteria for
referred children during a clinical interview, Zucker et al. had GIDC versus those who were deemed subthreshold for the
two coders independently use this information to judge if the diagnosis. Of 10 specific measures, the threshold group showed
child met DSM criteria for GIDC (N = 31). For Criterion A, more cross-gender behavior than the subthreshold group and, of
the two raters agreed in 34 of the 36 cases (19 present, 15 these, six of the differences were statistically significant. This
absent). Because this research team did not find that Criterion was the first in a series of studies that provided at least some
B ‘‘worked’’ for girls, Criterion B ratings were limited to boys evidence of discriminant validity within samples of gender-
(N = 31). For this criterion, the two raters agreed in 28 of the referred children, i.e., those threshold versus subthreshold for
31 cases (16 present, 12 absent). the diagnosis of GID (for further discussion, see below).
Comparative studies of the sex-typed behavior of children
referred for potential problems in their gender identity devel-
1
opment versus various control groups (siblings, clinical con- As noted in Zucker (2005a), there is some debate in the literature
regarding decision rules for calculating an effect size. In calculating
trols, and non-referred controls) have been the most common
Cohen’s d (M1 - M2/SD), one can use the pooled SD of two groups or
method to establish the validity of the GID diagnosis (Zucker, the SD of the control group. In calculating normative gender differences
1992). Such studies have relied on a variety of measurement for d, there is really no control group, so it is customary to use the pooled
approaches: item analysis from questionnaires, standardized SD; however, when comparing a group of probands with a control group,
it can be argued that the SD of the control group is more appropriate than
behavioral observations, projective tests or psychometrically
the pooled SD (see, e.g., Glass, McGaw, & Smith, 1981, pp. 106–107).
sound questionnaires (for a summary review of commonly used If the variance for the control group is considerably smaller than the
measures, see Zucker, 2005a). As I will argue in more detail variance for the probands, d will be larger if only the control group SD is
below, this line of research constitutes some of the strongest used, and this may well be important to consider with regard to clinical
matters. In Zucker (2005a), the more conservative effect size formula
evidence for the validity of the GID diagnosis vis-à-vis the
was used because this was what most authors used in their own studies.
psychometric concept of ‘‘discriminant validity’’ (cf. Rutter, Effect size calculations would be substantially higher if only the control
1978). group SD was used (see, e.g., Johnson et al., 2004).
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480 Arch Sex Behav (2010) 39:477–498
From this first wave of empirical studies regarding dis- concomitant rejection of ‘‘male stereotypical toys, games, and
criminant validity (for reviews, see Zucker, 1992; Zucker & activities.’’ The wording for B2 was identical to its wording in
Bradley, 1995), there appeared to be reasonable evidence for DSM-III.
diagnostic specificity.
Comment and Critique
DSM-III-R
The revised DSM-III-R criteria were formulated by a panel of
Table 2 shows the DSM-III-R diagnostic criteria for GIDC. The experts, i.e., by at least some members of the Subcommittee
structure of the criteria was similar to that in DSM-III, but there on Gender Identity Disorders who had clinical and research
were some important changes in wording and in the content experience with this population. The criteria were not subject
of the criteria. For both girls and boys, the phrase ‘‘[p]ersistent to any formal field trials for the purpose of establishing diag-
and intense distress about being a girl (boy)’’ was added to the nostic reliability or validity.
Point A criterion. For girls, the phrase ‘‘strongly and persistently In one critique of the DSM-III-R criteria, Zucker (1992)
stated desire to be a boy’’ now read as ‘‘a stated desire to be a noted that the addition of the distress passage in Criterion A was
boy.’’ For boys, the phrase ‘‘strongly and persistently stated de- not accompanied by any formal guidelines regarding how it
sire to be a girl’’ now read as ‘‘an intense desire to be a girl.’’ For should be assessed nor was it made clear in what ways the dis-
the Point B criterion for girls, B1 was new and pertained to a tress was considered distinct from other operationalized com-
girls’ marked rejection of the wearing of ‘‘normative feminine ponents in the Point A criteria. It was also noted that the remain-
clothing’’ and an ‘‘insistence on wearing stereotypical mascu- der of the descriptive material in Point A had a subtle difference
line clothing…’’ and the wording for B2 (pertaining to anato- between the two sexes. For girls, a ‘‘stated desire to be a boy’’
mic dysphoria) was modified from how it was formulated in was required whereas, for boys, an ‘‘intense desire to be a girl’’
DSM-III. For the Point B criterion for boys, B1 introduced a was required. In addition, the phraseology for girls did not ad-
dress the issue of intensity or some other variable pertaining to
Table 2 DSM-III-R diagnostic criteria for Gender Identity Disorder of duration (see Morgan, 2000). Why these distinctions appeared
Childhood in the DSM-III-R was not clear because the phraseology in
For females Criterion A for the two sexes was identical in the DSM-III.
A. Persistent and intense distress about being a girl, and a stated desire to Langer and Martin (2004) noted that this distinction appeared to
be a boy (not merely a desire for any perceived cultural advantages result in a lower threshold for boys than for girls in that boys did
from being a boy), or insistence that she is a boy not have to verbalize the desire to be a girl. On the other hand, it
B. Either (1) or (2) could be argued that the threshold was, in fact, lower for girls
(1) persistent marked aversion to normative feminine clothing and than for boys because it lacked an intensity criterion.
insistence on wearing stereotypical masculine clothing, e.g.,
boys’ underwear and other accessories
As I have noted elsewhere (Zucker, 2006a), it is not clear why
the DSM-III-R wound up changing the criteria for boys to ‘‘an
(2) persistent repudiation of female anatomic structures, as evidence
by at least one of the following intense desire’’ to be a girl from a ‘‘strongly and persistently
(a) an assertion that she has, or will, grow a penis stated desire.’’ The original was clearly more stringent. As a
(b) rejection of urinating in a sitting position member of the DSM-III-R Subcommittee on Gender Identity
(c) assertion that she does not want to grow breasts or menstruate Disorders, I have reviewed my own correspondence file and
C. The girl has not yet reached puberty. could find no indication that this distinction was either noted
For males or commented upon by the Subcommittee at large. My conclu-
A. Persistent and intense distress about being a boy and an intense desire
sion, as stated in Zucker (2006a), was that ‘‘the committee just
to be a girl, or, more rarely, insistence that he is a girl goofed.’’ It is also conceivable that the distinctions in phrase-
B. Either (1) or (2) ology were overlooked in the context of the added proviso
(1) preoccupation with female stereotypical activities, as shown by a of ‘‘persistent and intense distress.’’
preference for either cross-dressing or simulating female attire,
or by an intense desire to participate in the games and pastimes of Reliability and Validity
girls and rejection of male stereotypical toys, games, and
activities
To my knowledge, no formal studies examined the reliability of
(2) persistent repudiation of male anatomic structures, as manifested
by at least one of the following repeated assertions the DSM-III-R diagnostic criteria for children, i.e., inter-clini-
(a) that he will grow up to become a woman (not merely in role) cian agreement. As during the DSM-III era, the most common
(b) that his penis and testes are disgusting or will disappear line of evidence for validity involved comparative studies of
(c) that it would be better not to have a penis or testes gender-referred children versus that of various control groups
C. The boy has not yet reached puberty along with comparisons of gender-referred children deemed
threshold versus subthreshold based on clinician diagnosis. I
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Arch Sex Behav (2010) 39:477–498 481
will not review these studies here, as the same type of inter- Table 3 DSM-IV diagnostic criteria for Gender Identity Disorder (for
pretive overview would apply to them as to the wave of DSM-III children)
era studies (for references, see Zucker, 1992; Zucker & Bradley, A. A strong and persistent cross-gender identification (not merely a
1995; Zucker, Bradley, & Sanikhani, 1997; Zucker, Lozinski, desire for any perceived cultural advantages of being the other sex)
Bradley, & Doering, 1992; Zucker et al., 1993, 1999). Some of In children, the disturbance is manifested by at least four (or more) of the
the more important studies using mixed samples of DSM-III-R following
and DSM-IV era patients are, however, reviewed in some detail (1) repeatedly stated desire to be, or insistence that he or she is, the
other sex
below.
(2) in boys, preference for cross-dressing or simulating female attire;
in girls, insistence on wearing only stereotypical masculine
Predictive Validity clothing
(3) strong and persistent preferences for cross-sex roles in make-
Wallien and Cohen-Kettenis (2008) reported psychosexual fol- believe play or persistent fantasies of being the other sex
low-up data on 77 gender-referred children (59 boys, 18 girls), (4) intense desire to participate in the stereotypical games and pastimes
originally assessed at a mean age of 8.4 years (range, 5–12). At of the other sex
the time of follow-up, the mean age was 18.9 years (range, 16– (5) strong preference for playmates of the other sex
28). Regarding gender identity at follow-up, 21 children (12 boys, B. Persistent discomfort with his or her sex or sense of inappropriateness
9 girls) were classified as persisters, i.e., these children were still in the gender role of that sex
gender dysphoric and were seen clinically because of an ongoing In children, the disturbance is manifested by any of the following: in
boys, assertion that his penis or testes are disgusting or will disappear
desire for sex-reassignment (hormonal and surgical treatment); or assertion that it would be better not to have a penis, or aversion
the remaining 56 children were classified as desisters (i.e., they toward rough-and-tumble play and rejection of male stereotypical
were no longer gender-dysphoric), either based on a formal toys, games, and activities; in girls, rejection of urinating in a sitting
re-assessment or because they had not re-contacted the clinic position, assertion that she has or will grow a penis, or assertion that
she does not want to grow breasts or menstruate, or marked aversion
requesting sex-reassignment. Of the 21 persisters, all had re- toward normative feminine clothing
ceived a DSM-III-R diagnosis of GIDC at the time of assessment C. The disturbance is not concurrent with a physical intersex condition
in childhood, compared to 37 (66.0%) of the desisters, a signifi- D. The disturbance causes clinically significant distress or impairment
cant difference. On two dimensional measures of cross-gender in social, occupational, or other important areas of functioning
identity, the Gender Identity Questionnaire for Children (GIQC)
(Johnson et al., 2004) and the Gender Identity Interview for
Children (GIIC) (Wallien et al., 2009; Zucker et al., 1993), the
persisters showed significantly more cross-gender behavior and
child was deemed to meet this criterion if he or she manifested one
gender identity confusion than the desisters. Thus, using both
of two indicators.
categorical diagnosis and dimensional measures, Wallien and
Compared to the diagnostic criteria for GIDC in DSM-III-
Cohen-Kettenis provided some evidence for predictive validity
R, there were five changes to the criteria set:
vis-à-vis persistence versus desistance. In my view, these data
constitute an important addition to the empirical literature 1. In contrast to both DSM-III and DSM-III-R, Criterion A
regarding the validity of the GIDC criteria. contained the proviso ‘‘not merely a desire for any per-
ceived cultural advantages of being the other sex’’ for
DSM-IV both boys and girls, not just for girls.
2. The distress element of the Point A criterion in DSM-III-
Table 3 shows the DSM-IV child criteria for GID. For the DSM- R (e.g., ‘‘[p]ersistent and intense distress about being a
IV, the Subcommittee on Gender Identity Disorders (Bradley girl…’’) was deleted and moved to the Point D clinical
et al., 1991) reviewed the merit of altering the criteria for children significance criterion. Note that the clinical significance
to a polythetic format, in which various behavioral traits would be criterion was added to about half of the DSM-IV diagno-
operationalized, from which a specified number would be re- ses (see Spitzer & Wakefield, 1999; Wakefield & First,
quired to meet the criteria for the diagnosis of GID. In its final 2003).
form, there were two clinical indicator (symptom) criteria. As 3. For both boys and girls, the verbalized desire to be of the
shown in Table 3, Criterion A was described as ‘‘[a] strong and other sex was no longer a distinct criterion. Rather, in
persistent cross-gender identification (not merely a desire for any DSM-IV, it became one of five indicators for Criterion A.
perceived cultural advantages of being the other sex)’’ (p. 537) In contrast to DSM-III-R, this criterion was harmonized
and a child was deemed to meet this criterion if he or she mani- (equalized) for boys and girls. In DSM-III-R, girls only
fested at least four of the five indicators. Criterion B was described required a ‘‘stated desire’’ to be a boy, whereas boys were
as a ‘‘[p]ersistent discomfort with his or her sex or sense of required to have ‘‘an intense desire’’ to be a girl (as noted
inappropriateness in the gender role of that sex’’ (p. 537) and a earlier, the absence of an ‘‘intensity’’ qualifier for girls
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482 Arch Sex Behav (2010) 39:477–498
was likely an oversight). Thus, in DSM-IV, Criterion A1 presented a couple of difficulties (Zucker, 1992). First, it made
was written in a manner such that it could be applied an etiological or motivational assumption about a girl’s desire to
equally to both boys and girls. be a boy (e.g., that one type of desire was based on a perception
4. For boys, the other behavioral indicators of cross-gender of cultural disadvantage or bias, whereas at least one other un-
identification (A2–A5) were better separated (in DSM- specified type was not). A similar such assumption was not
III-R, for example, two of these were given as examples applied to boys. Although this distinction might have relevance
of the B1 criterion) (see Table 2). For girls, three of these for such parameters as natural history and response to treatment,
four behavioral indicators were new, as they were not I argued that it was unclear why it should be used diagnostically
explicitly required for girls in the DSM-III-R (A2, which (Zucker, 1992). I also argued that the absence of this proviso for
pertained to cross-dressing, was extracted from the B1 boys was puzzling because, in principle, a boy may wish to be a
criterion in DSM-III-R). girl because of a similar, albeit inverted, perception of cultural
5. For Criterion B, for boys, there remained some similarity to disadvantage or bias (e.g., that girls get to wear dresses, are not
the B1 criterion in DSM-III-R: the criterion was deemed yelled at as much, do not have to play rough, and so on). I
met if a boy displayed signs of anatomic dysphoria or dis- concluded that, if such rationales were to be construed in cultural
played an ‘‘aversion toward rough-and-tumble play and re- terms, the potential for bias should apply equally to both sexes
jection of male stereotypical toys, games, and activities’’ (Zucker, 1992). I will provide a clinical vignette that illustrates
(emphasis added). For girls, there also remained some sim- how the cultural proviso could create a diagnostic dilemma:
ilarity to the B1 criterion in DSM-III-R: the criterion was
A 5-year-old girl (IQ = 107) was referred for assessment
deemed met if a girl displayed signs of anatomic dysphoria
by a relative, who was a health care professional. She lived
or displayed a ‘‘marked aversion toward normative fem-
with her mother and an older sibling. The biological father
inine clothing.’’
was deceased. At the time of assessment, the girl met all of
the DSM-IV criteria for GID. Her mother was petrified to
know why her daughter either insisted that she was a boy
Comment and Critique
or that she had a strong desire to become one. Thus, she
had never asked her daughter why she wanted to be a boy
Since the publication of DSM-IV, there have been various cri-
or thought that she was one. In the family interview, the
tiques leveled at the GID diagnosis at it applies to children. In
mother was encouraged to do so and her daughter replied
this section, I will review the key conceptual and procedural
by stating: ‘‘Because I like boys’ underwear. Girls can’t
criticisms. I will not, however, formally address the most fun-
wear boys’ underwear. That is why I want to be a boy.’’
damental criticism, namely that GID is not a mental disorder and
should be removed from the DSM in its entirety. On this point, If one cast this remark under a cultural bias lens, one could
Meyer-Bahlburg (2009) has addressed the competing views on make the argument that her perception that only boys can wear
this broad philosophical debate (see also Bockting, 2009). I will boys’ underwear would rule out the diagnosis of GID. Of course,
also not address some of the putative sociopolitical criticisms one could always counter that the girl’s reasoning about why
of the GID diagnosis (see, e.g., Feder, 1997; Hegarty, 2009; she desired to be a boy was not the ‘‘real’’ reason–that it was sim-
Martin, 2008; Minter, 1999; Morgan, 2000; Sedgwick, 1991), ply her own, idiosyncratic gendered social construction. This,
such as the claim that it was introduced into the DSM-III as a however, moves into the realm of making causal assumptions,
backdoor maneuver to replace homosexuality (e.g., Ault & which the criteria are not intended (at least in theory) to address.
Brzuzy, 2009), which had been delisted from the DSM-II The DSM-IV Subcommittee on Gender Identity Disorders
in 1973. On this point, I have provided my own view else- (Bradley et al., 1991) had taken the position that ‘‘it was
where (Zucker & Spitzer, 2005; see also Meyer-Bahlburg, inappropriate to place such an exclusion rule in the criteria
2009; Zucker, Drummond, Bradley, & Peterson-Badali, 2009). themselves, as there may be many reasons why a child adopts
Regarding sociopolitical issues in general, Drescher (2009) has a cross-gender identity, and that these issues should be dealt
provided an overview of this topic. In appraising the criticisms, with in the text’’ (p. 326). Although differential diagnostic
I will attempt to address them, when possible, with empirical parameters continued to receive attention in the DSM-IV
data. text, the decision adopted by the American Psychiatric Asso-
ciation was to harmonize (equalize) the cultural proviso for
boys and girls in Criterion A.
The Cultural Consideration Proviso in Point A
Criteria for Cross-Dressing
This aspect of the Point A criteria has received little empirical
attention. In a critique of this proviso as it appeared in DSM-III Of the five indicators for GID in the Point A criterion (see
and DSM-III-R, I have previously argued that this exclusion rule Table 3), four were written in a manner such that they were
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Arch Sex Behav (2010) 39:477–498 483
identical for boys and girls (A1, A3–A5). As noted by Langer perhaps for social desirability reasons, such a boy might not
and Martin (2004), the criterion for cross-dressing (A-2) has overtly verbalize the desire to be a girl. The clinical opinion at that
somewhat different wording for boys versus girls: ‘‘in boys, time was that this particular configuration might be particularly
preference for cross-dressing or simulating female attire; in characteristic of older children.
girls, insistence on wearing only stereotypical masculine Empirical evidence was then examined to justify the change
clothing’’ (American Psychiatric Association, 2000, p. 581) for the Criterion A indicators. As reported in Zucker et al.
(see also Morgan, 2000); however, Langer and Martin failed (1998), factor analysis of 7 interviewer-rated items and 14
to note that there is an additional sex difference regarding maternally-rated items pertaining to cross-gender identifica-
the surface indicator of clothing preference. In the Point B tion from Green’s (1987) database of 66 feminine boys and
criterion (see Table 3), there is the indicator, for girls, of a 55 control boys identified a one-factor solution, containing 15
‘‘marked aversion toward normative feminine clothing,’’ but items with factor loadings C.40. One of these items, ‘‘Son
there is no corresponding parallel indicator for boys (i.e., a states wish to be a girl,’’ had a factor loading of .61. The other
marked aversion toward normative masculine clothing). 14 items had factor loadings ranging from .44–.84. It was thus
Regarding the Point A criterion, Langer and Martin inter- argued that the wish to be of the other sex was simply one of a
preted the sex difference regarding the cross-dressing criterion number of behaviors suggestive of cross-gender identification.
as indicating a ‘‘lower diagnostic threshold for boys’’ (p. 8). In The conceptual notion that cross-gender identification has
my view, the differences in the Point A criterion appear rather an underlying single-factor structure has received subsequent
subtle and it is not clear why the wording is not similar for boys empirical support. Johnson et al. (2004), for example, factor-
and girls (e.g., ‘‘in girls, preference for cross-dressing or simu- analyzed the 16-item GIQC (see above) in a large sample of
lating male attire’’). My clinical hunch is that the slightly higher gender-referred children (N = 325) and control children
threshold for girls is related to the more general concern that the (N = 504). Johnson et al. found that two items pertaining to a
DSM makes clear that, for girls with GID, there is an extreme cross-sex wish (Boy version: ‘‘He states the wish to be a girl or a
rejection of wearing culturally typical feminine clothing (as woman’’ and ‘‘He states that he is a girl or a woman’’) had factor
reflected in the Point B indicator). Clinically, there are some loadings of .81 and .69, respectively, and loaded on a single, 14-
clear sex differences in the way that boys and girls manifest factor solution. Eleven other items pertaining to cross-gender
cross-dressing. Many boys with GID will not object to wearing identification had factor loadings that ranged from .34–.91. A
culturally typical masculine clothing (e.g., pants and shirts) to twelfth item (Boy version: ‘‘He talks about not liking his sexual
school, but will resort to cross-dressing when the setting permits anatomy (private parts))’’ had a factor loading of .47.
it (e.g., in the dress-up corner at nursery school, during fantasy In Green’s (1987) data set, there was empirical support for
play at home, etc.). In contrast, many girls with GID experience the hypothesis that the verbalized wish to be of the other sex was
the wearing of culturally typical feminine clothing (e.g., dres- less common in older boys (9–12 years of age) than in younger
ses) as quite catastrophic and will refuse to wear them under any boys (3–9 years of age) (Zucker et al., 1998). Zucker et al. then
circumstances. Many parents of girls with GID report that one of reexamined symptom ratings from parent interview data for 54
its earliest indicators pertained to extreme anxiety and unease children seen at the Toronto Child and Adolescent Gender
around clothing and hair-style. Thus, the preference for mas- Identity Clinic who did not meet DSM-III criteria for GIDC. In
culine clothing and the rejection of feminine clothing is often this analysis, they assessed whether these children would meet
one of the most salient and emotionally charged surface indi- the proposed Criterion A for DSM-IV with regard to the A2–A5
cators of gender dysphoria in young girls. indicators (none of these 54 children had repeatedly verbalized
the desire to be of the other sex). For the 54 children, the mean
Revision of the Point A Criteria number of indicators rated as present was 2.36 (SD = 1.33;
range, 0–4). Of the 54 children, 16 (29.6%) had all four indi-
Because the collapsing of the verbalized wish to be of the other cators and thus would meet the proposed threshold for Criterion
sex with other behavioral indicators of cross-gender identification A. The subgroup that now met the threshold was compared with
has received substantial criticism (see below), I will summarize the subgroup that did not with regard to the demographic vari-
here the rationale for it during the preparation phase for DSM-IV. ables of age, IQ, and parent’s social class and marital status.
Clinical opinion at that time was that some children who appeared There was a trend for the children who were at threshold for
to be struggling with their gender identity did not, at least at the Criterion A to be younger than the children who were not at
time of a clinical evaluation, verbalize the desire to be of the other p = .087, two-tailed. None of the other demographic variables
sex (Bradley et al., 1991). For example, it was argued that a boy significantly distinguished the two subgroups.
who met the A2–A5 criteria and displayed an ‘‘aversion toward Zucker et al. (1998) concluded that the revised criteria
rough-and-tumble play and rejection of male stereotypical toys, resulted in a modest increase in ‘‘diagnosed’’ cases; however,
games, and activities’’ (Criterion B) was unlikely to have a very they also noted that this increase was likely an overestimate
positive sense of self as a boy. Clinical impression was that, as the Criterion B indicators were not examined, including
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484 Arch Sex Behav (2010) 39:477–498
the ‘‘aversion toward rough-and-tumble play and rejection Willoughby, 2007; Moore, 2002; Richardson, 1996, 1999; Wil-
of male stereotypical toys, games, and activities.’’ If any- son, Griffin, & Wren, 2002).2 Thus, it has been claimed that
thing, it would be likely that some of the children who met the Point A criterion blurs the distinction between a child who
the threshold for Criterion A would not meet the threshold has both a cross-gender identity and pervasive cross-gender
for Criterion B. behavior and a child who merely shows signs of pervasive cross-
gendered behavior (in descriptive terms, the ‘‘gender noncon-
Conflation of Cross-Gender Behavior and Gender Dysphoria forming’’ or ‘‘gender-variant’’ child). As a result, there is the
concern that children might be inappropriately diagnosed with
In many respects, cross-gender identification and GID proper GID simply because they meet the A2–A5 criteria. (As an aside,
can only be understood in a social and phenomenological (i.e., in clinical practice, it is quite rare to assess a child who shows
subjective) context (Money, 1994; Zucker, 1999). Apart from only signs of a cross-gender identity (A1) in the absence of
any biological predisposition that underlies both normative pervasive cross-gender behavior (A2–A5).)3
and atypical gender development, children construct a gender Based on this criticism, Bartlett et al. (2000) suggested that the
identity based on information that they glean from the social Point A criteria might capture two subgroups of children. In ap-
environment. Cognitive-developmental gender theorists, for praising the Zucker et al. (1998) data discussed earlier, Bartlett
example, suggest that once children become aware of a ‘‘two- et al. surmised that ‘‘…the data might be better viewed as re-
gendered’’ social world and develop the capacity for gender flective of a common [co-occurrence] of cross-sex wishes and
identity self-labeling they then scan their environment for cross-gender behaviors, but not a complete overlap…perhaps
information about ‘‘what boys do’’ and ‘‘what girls do’’ and those children who express cross-sex wishes may be expected to
then often adopt behavioral patterns that are consistent with also exhibit cross-gender behaviors, though children who exhibit
their own gender identity (Martin & Ruble, 2004; Martin, cross-gender behaviors may not necessarily be expected to also
Ruble, & Szkrybalo, 2002). experience the desire to be the other sex’’ (p. 758). Bartlett et al.’s
In my view, the A2–A5 behavioral indicators of cross-gender suggestion would lead to the following two hypotheses: (1) gen-
identification adopted in the DSM-IV were framed in relation to der-referred children would, on average, show more cross-gender
what is known about normative or typical gender development. behavior than that of control children, regardless of whether or not
The core behavioral attributes that constitute these indicators they expressed the desire to be of the other sex; (2) the degree of
(dress-up play, fantasy role play, toy and activity preferences, cross-gender role behavior of gender-referred children would
and sex-of-playmate preference) rest on the assumption that vary as a function of their verbalized desire to be of the other sex.
they are, on average, sex-dimorphic, i.e., they show significant To test these hypotheses, I re-analyzed data from the GIQC
differences between typical boys and girls. As one example: for 438 gender-referred children (359 boys, 79 girls) and 807
boys with cross-gender identification or GID proper who adopt control children (504 boys, 303 girls) seen in my clinic. For the
cross-gender roles in fantasy play (e.g., emulating various fe- gender-referred children, I partitioned them into five subgroups
male characters—mother, sister, Snow White, The Little Mer- based on their stated desire to be of the other sex (GIQC Item
maid, Batgirl, Princess Lea or Asajj Ventress from Star Wars, 13), ranging from ‘‘every day’’ to ‘‘never.’’ Then, I calculated a
etc.) presumably do so, in part, because, on average, girls are
more likely to adopt such role choices than boys. Johnson et al.
2
(2004) found strong evidence for this on the parent-report Bryant (2006, pp. 31–33) has provided an interesting historical
perspective on the GIDC diagnosis prior to its formal appearance in the
GIQC. For the item, ‘‘In playing ‘mother/father,’ ‘house,’ or
DSM-III. Using unpublished correspondence (for details, see Bryant,
‘school games’’’, 92.6% (188/203) of control boys were judged 2007), much channeled through the office of Robert L. Spitzer, Bryant
to be ‘‘usually a boy or man’’ or ‘‘a boy or man at all times’’ has shown that the debate regarding the distinction between cross-
whereas 95.5% (171/179) of controls girls were judged to be gender identity and cross-gender role behavior was apparently a key
‘‘behind the scenes’’ issue in the 1970s. Prior to the adoption of the GIDC
‘‘usually a girl or woman’’ or ‘‘a girl or woman at all times.’’ In
name for the diagnosis, other naming options had been proposed,
contrast, 61.9% of gender-referred boys were judged to be including Psychosexual Identity Disorder, Gender Role Disorder of
‘‘usually a girl or woman’’ or ‘‘a girl or woman at all times’’ and Childhood, and Gender Identity or Role Disorder of Childhood. At that
68.4% of gender-referred girls were judged to be ‘‘usually a boy time, feedback given to the Psychosexual Disorders Committee (which
apparently had a subcommittee called the Gender Role Disorders
or man’’ or ‘‘a boy or man at all times.’’ For the control boys
Committee or the Gender Identity/Role Disorders Committee) included
versus girls, the effect size was 3.60 (my analysis). the concern that the proposed diagnostic criteria did not adequately
Critics of the DSM-IV Point A criteria have argued that they distinguish between cross-gender role behaviors and a cross-gender
inappropriately condense cross-gender identity (the desire to be identity proper (see also Bryant, 2007, 2008).
3
of the other sex), as reflected in A1, and pervasive cross-gender Other terms to describe children who might meet the DSM-IV criteria
for GID are ‘‘girlyboys’’ (e.g., Corbett, 1996; Ehrensaft, 2007), which
role behaviors, as reflected in A2–A5 (Bartlett, Vasey, & Bu-
seems to have supplanted the older term of ‘‘sissy boys’’ (Green, 1987),
kowski, 2000; Bockting & Ehrbar, 2005; Bryant, 2007; Corbett, ‘‘gender-dissonant’’ (Vanderburgh, 2009), and ‘‘transgender’’ children
1996, 1998; Haldeman, 2000; Hill, Rozanski, Carfagnini, & (Brill & Pepper, 2008).
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Arch Sex Behav (2010) 39:477–498 485
5 5
Mean GIQC Score

4
Mean GIOC Score
3 3
2 2
1 1
1 2 3 4 5 CONT 1 2 3 4 5 CONT
Fig. 1 Maternal ratings of cross-gender behavior on the GIQC as a Fig. 2 Maternal ratings of cross-gender behavior on the GIQC as a
function of Item 13 (stated desire to be of the other sex). A lower score function of Item 14 (insistence that one is of the other sex). A lower score
indicates more cross-gender behavior. Note: On the horizontal axis, indicates more cross-gender behavior. Note: On the horizontal axis,
1 = ‘‘every day’’ (N = 23); 2 = ‘‘frequently’’ (N = 85); 3 = ‘‘once- 1 = ‘‘every day’’ (N = 14); 2 = ‘‘frequently’’ (N = 54); 3 = ‘‘once-
in-a-while’’ (N = 158); 4 = ‘‘very rarely’’ (N = 83); 5 = ‘‘never’’ in-a-while’’ (N = 83); 4 = ‘‘very rarely’’ (N = 69); 5 = ‘‘never’’
(N = 89). For the controls, N = 807 (N = 218). For the controls, N = 807
revised GIQC mean score based only on the 11 GIQC items did not differ significantly in their degree of cross-gender role
(Items 1–7, 9–12) pertaining to cross-gender role behavior (or behavior.
same-gender role behavior) that had acceptable factor loadings I conducted a similar analysis as a function of the GIQC item
on the factor described in Johnson et al. (2004). pertaining to the child’s insistence that he or she was a member
Figure 1 shows the mean revised GIQC score as a function of of the other sex (Fig. 2). A 2 (Sex) 9 5 (Insistence) ANCOVA
the verbalized wish to be of the other sex. For reference pur- yielded a significant main effect for Insistence, F(4, 432) =
poses, the mean revised GIQC score of the control children is 19.61, p \ .001. Duncan’s post hoc tests showed that the chil-
also shown in the figure. It can be seen in Fig. 1 that the gender- dren who insisted that they were the other sex either ‘‘every day’’
referred children had, on average, significantly more cross- or ‘‘frequently’’ had, on average, significantly more cross-gen-
gender role behavior than did the control children. Even the der role behavior than children who ‘‘very rarely’’ or ‘‘never’’
subgroup of gender-referred children who did not verbalize the insisted as such, but their mean score did not differ significantly
wish to be of the other sex had significantly more maternally- from the children who verbalized such a statement ‘‘once-in-a-
rated gender-atypical behavior than did the control children, while.’’ The latter group did not differ significantly from the
t(894) = 20.78, p \ .001 (d = 2.32). Thus, this finding sup- children who verbalized such a statement ‘‘very rarely’’ but
ports the first hypothesis advanced by Bartlett et al. (2000). had, on average, significantly more cross-gender role behav-
For the gender-referred children alone, I then calculated a ior than the children who ‘‘never’’ verbalized this remark. The
2 (Sex) 9 5 (Wish) analysis of covariance (ANCOVA). Age ‘‘very rarely’’ and ‘‘never’’ subgroups did not differ signifi-
was covaried because the children who, by maternal report, cantly from each other (all significant p values\.05).
‘‘never’’ verbalized the wish to be of the other sex were signif- In my view, these two analyses support Bartlett et al.’s (2000)
icantly older than the children who ‘‘frequently’’ verbalized the second hypothesis, namely that the degree of cross-gender role
wish (p \ .05). None of the other paired age contrasts differed behavior among gender-referred children is related to the fre-
significantly. It can be seen in Fig. 1 that the degree of cross- quency with which they express the desire to be of the other sex
gender role behavior showed a very clear linear relation to the (or the insistence that they are a member of the other sex).
frequency of the verbalized cross-sex wish. The formal statis- In the analyses conducted so far, it could be argued that a
tical test via ANCOVA yielded a significant main effect for methodological constraint is that the informant (i.e., the
Wish, F(4, 432) = 30.90, p \ .001. Duncan’s post hoc tests mother) was rating both the gender-role items and the two
showed that children who verbalized the desire to be of the other items pertaining to the verbalized desire to be, or insistence
sex ‘‘every day’’ or ‘‘frequently’’ had, on average, significantly that one is, of the other sex. Thus, there is, perhaps, the prob-
more cross-gender role behavior on the GIQC than the children lem of a ‘‘halo’’ effect, i.e., the higher one rates one class
who verbalized a cross-sex wish ‘‘once-in-a-while,’’ ‘‘rarely,’’ of behaviors, the higher one would rate the other class. In
or ‘‘never.’’ The children who verbalized a cross-sex wish ‘‘once- Johnson et al. (2004), it was, however, reported that the
in-a-while’’ had, on average, significantly more cross-gender mother–father correlation for the total GIQC score was sub-
role behavior than the children who either ‘‘rarely’’ or ‘‘never’’ stantial, at r = .90, which, perhaps lends some confidence in
verbalized the wish (all ps \ .05). The latter two subgroups the accuracy of the maternal ratings.
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486 Arch Sex Behav (2010) 39:477–498
To explore the empirical issue further, I examined the rela- 20

tion between maternal ratings of the desire to be of the other sex
and child report of gender identity confusion on the Gender Iden-
Mean GII Sum Score

15
tity Interview for Children, a structured questionnaire schedule
(Wallien et al., 2009; Zucker et al., 1993). The GIIC consists of
12-items, each rated on a 3-point response scale. The GIIC has 10
been shown in two independent analyses, including one con-
firmatory factor analysis (CFA), to have a two-factor solution,
5
consisting of 4 items labeled as Cognitive Gender Confusion
and 8 items labeled as Affective Gender Confusion. For the pur-
poses of this analysis, the unit-weighted sum score for all 12 0
items was calculated. In this analysis, there were GIIC scores for 1 2 3 4 5 CONT
332 gender-referred boys and 75 gender-referred girls.
Figure 3 shows the mean GIIC score as a function of the Fig. 4 Gender Identity Interview Sum Score as a Function of Item 14
(insistence that one is of the other sex) on the GIQC. On the horizon-
verbalized wish to be of the other sex. With age covaried, a 2
tal axis, 1 = ‘‘every day’’ (N = 13); 2 = ‘‘frequently’’ (N = 49); 3 =
(Sex) 9 5 (Wish) ANCOVA yielded a significant main effect ‘‘once-in-a-while’’ (N = 81); 4 = ‘‘very rarely’’ (N = 66); 5 = ‘‘never’’
for Wish, F(4, 401) = 22.97, p \ .001. Like the GIQC data, (N = 198). For the controls, N = 173 (GIIC data for the gender-referred
there was a clear linear relationship between these two param- probands from Wallien et al. (2009) and Zucker et al. (1993); control
data from Wallien et al. (2009)). On the GIIC, absolute range is 0–24
eters. For example, children who verbalized the wish to be of the
other sex ‘‘every day’’ had a significantly higher GIIC mean
score than the other four subgroups. All paired contrasts were
statistically significant (p \ .05), except the comparison be- These results showed a convergence between the degree to
tween the children who ‘‘very rarely’’ verbalized the desire to be which the mothers perceived their children to express the
of the other sex and those who ‘‘never’’ verbalized such a desire. desire to be, or insistence that they are, a member of the other
I conducted a similar analysis as a function of the GIQC item sex and the degree of child-reported gender identity confu-
pertaining to the child’s insistence that he or she was a member sion/dysphoria on the GIIC.
of the other sex (Fig. 4). A 2 (Sex) 9 5 (Insistence) ANCOVA
yielded a significant main effect for Insistence, F(4, 432) = Reliability and Validity
19.61, p \ .001. Children who insisted that they were of the
other sex ‘‘frequently’’ or ‘‘every day’’ had a significantly higher Since the DSM-IV criteria for GID in children were published,
GIIC mean score than the other three groups; the children who there have been no formal reliability studies of the GID diag-
insisted they were of the other sex ‘‘once-in-a-while’’ had a nosis for children. By this, I mean that there have been no studies
significantly higher GIIC mean score than the children who that have reported inter-clinician agreement on the diagnosis.
‘‘never’’ made such remarks (all ps \ .05). This is a serious deficiency in the literature. If the GID diagnosis
for children is to remain in the DSM-V, it would be important to
20
conduct field trials that establish the diagnostic reliability of the
criteria, however they are formulated.
Mean GII Sum Score
15 As was the case for pre-DSM-IV cohorts, a number of studies

have demonstrated reasonable evidence of discriminant valid-
ity. There have been at least seven such studies in the DSM-IV
10 era (Chiu et al., 2006; Cohen-Kettenis, Owen, Kaijser, Bradley,
& Zucker, 2003; Cohen-Kettenis et al., 2006; Fridell, Owen-
Anderson, Johnson, Bradley, & Zucker, 2006; Johnson et al.,
5
2004; Wallien, Veenstra, Kreukels, & Cohen-Kettenis, 2009;
Wallien et al., 2009). In some of these studies, data on specific-
0 ity and sensitivity have been examined. In general, it has been
1 2 3 4 5 CONT argued that specific psychometric measures should have a high
Fig. 3 Gender Identity Interview Sum Score as a function of Item 13 threshold for specificity, that is, to have a low rate of false pos-
(stated desire to be of the other sex) on the GIQC. On the horizontal axis, itives for controls. In Johnson et al. (2004), the specificity rate
1 = ‘‘every day’’ (N = 22); 2 = ‘‘frequently’’ (N = 80); 3 = ‘‘once- was set at 95%, which yielded a sensitivity rate of 86.8% for
in-a-while’’ (N = 149); 4 = ‘‘very rarely’’ (N = 76); 5 = ‘‘never’’
the gender-referred probands (which improved to 96.3% when
(N = 80). For the controls, N = 173 (GIIC data for the gender-referred
probands from Wallien et al. (2009) and Zucker et al. (1993); control only probands who were threshold for the GID diagnosis were
data from Wallien et al. (2009)). On the GIIC, absolute range is 0–24 examined).
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Arch Sex Behav (2010) 39:477–498 487
Threshold Versus Subthreshold Comparative Analyses In one study in which DSM-III-R criteria were used,
Zucker and Bradley (1995) reported that the children who
Within clinic-referred samples of gender-referred children, the met the complete criteria for GID (n = 113) were signifi-
majority have been deemed to meet the complete DSM criteria for cantly younger, of a higher social class background, and more
GID based on clinician diagnosis. For example, in a cross-clinic, likely to come from an intact, two-parent family than the
cross-national study of gender-referred children (total N = 488) children who were subthreshold for GID (n = 80). The two
in Toronto and Utrecht, The Netherlands (Cohen-Kettenis et al., subgroups did not differ significantly with regard to sex
2003), the percentage who met the complete DSM criteria for GID composition and IQ. To test which variables, if any, con-
was 67.0%. Clinically, it has been noted that the majority of tributed to the correct classification of the subjects in the
subthreshold cases likely met the complete criteria at a younger two diagnostic groups, a discriminant function analysis was
age, but not at the time of assessment (Zucker & Bradley, 1995). performed. Age, sex, IQ, and marital status contributed to the
As noted earlier, some critics have expressed concern that discriminant function, with age showing the greatest power.
the DSM criteria may not adequately differentiate children with In the threshold group, 82.6% were correctly classified and,
GID from those children who merely show a pattern of extreme in the subthreshold group, 68.8% were correctly classified.
‘‘gender nonconforming’’ behavior but who are not ‘‘truly’’ GID Several data sets have examined whether or not the two di-
(e.g., Corbett, 1996; Haldeman, 2000; Jalas, 2003; Richardson, agnostic subgroups differed on various measures of sex-typed be-
1996). Haldeman (2000), for example, claimed that ‘‘…it is havior. As summarized in Zucker and Bradley (1995), the
conceivable that a child could be diagnosed with GID exclu- threshold group showed significantly more cross-gender behav-
sively on the basis of preference for gender atypical activities or ior or less same-gender behavior than the subthreshold group on
play objects’’ (p. 195) or that ‘‘any boy who, for example, dis- 11 of 17 measures, even after controlling for the demographic
plays an even passing interest in art, music or cooking could, variables that also differed between the two subgroups (see also
conceivably, be diagnosed as GID…’’ (p. 198). Neither of these Zucker et al., 1984, summarized earlier).
assertions are likely to occur and, to date, critics of the diagnos- More recent studies, largely using DSM-IV criteria, have
tic criteria have not provided an empirical demonstration of continued to document significant differences between thresh-
systematic inaccurate diagnosis (Zucker, 2001). In contrast, one old and subthreshold cases. Johnson et al. (2004) found that
analogue-vignette study found that clinicians were prone to the subthreshold group (n = 109) had a mean score on the
‘‘profound underdiagnos[is]’’ of GID, i.e., they did not make the GIQC that was intermediate between that of the threshold
diagnosis even when the vignette included information that was cases (n = 216) and the controls. There was, however, clear
consistent with the DSM-IV criteria as currently formulated evidence that the subthreshold group was ‘‘gender noncon-
(Ehrbar, Witty, Ehrbar, & Bockting, 2008).4 forming’’ in that the effect size between their mean score and
Comparative analysis of threshold versus subthreshold cases that of the controls was substantial (Cohen’s d ranged from
is important for two reasons. First, using external measures, it 1.44 to 3.28 when blocked by age groups [e.g., 3–5 years, 5–
can indicate whether or not the DSM criteria reliably distinguish 6 years, etc.]). In a sample of gender-referred children from
between these two diagnostic subgroups; in other words, the Utrecht, Cohen-Kettenis et al. (2006) also found that the
central issue is one of identifying the boundary of a psychiatric threshold cases (n = 114) had a significantly more deviant
disorder (cf. Kendler, 1999). Second, if there is evidence that a score on the GIQC than did the subthreshold cases (n = 42).
valid distinction can be made, one can evaluate whether or not In my view, a particularly important study pertaining to
the subgroups differ in other ways, such as variation in long- the threshold–subthreshold distinction is that of Wallien et al.
term developmental trajectories, putative etiological factors, (2009). Wallien et al. conducted a CFA on the GIIC in a sample
and so on. of 329 gender-referred children from Toronto, 228 gender-
referred children from Amsterdam, and 173 control children
4
At least one clinician (Pleak, 1999) indicates that he does not use the GID from Toronto. The CFA documented the two-factor solution
diagnosis because of its potential for stigma. The relation between stigma
originally reported by Zucker et al. (1993). Both groups of
and psychiatric diagnosis for children is beyond the scope of this review;
however, it is important to point out that a psychiatric ‘‘label’’ can have gender-referred children had, on average, a significantly higher
positive (or stigma-reducing) effects and is not uniformly negative (stigma- score on the GIIC than did the control children, indicating more
enhancing) (see, e.g., Walker, Coleman, Lee, Squire, & Friesen, 2008). I gender identity confusion (Toronto-control effect size: 2.15;
also suggest Clausen (1981) as an excellent review essay that articulates
Amsterdam-control effect size: 3.46). More importantly for the
well the complex literature on psychiatric diagnosis and stigma. My own
view on stigma runs something like this: When children with GID are present discussion, the threshold cases had a significantly higher
socially ostracized by their peers, it is their overt behavior that elicits GIIC sum score (M, 9.58; SD = 5.70; N = 397) than did the
negative reactions (see, e.g., Fridell, 2001), not an abstract label (see, subthreshold cases (M, 4.68; SD = 4.18; N = 160). Not sur-
e.g., Law, Sinclair, & Fraser, 2007). There is considerable evidence that,
prisingly, the sensitivity rates were higher for the clients who
even in normative samples of children, cross-gender behavior is appraised
negatively by the peer group, and more so in boys than it is in girls (Zucker, met the complete DSM criteria for GID than for the clients who
Wilson-Smith, Kurita, & Stern, 1995). were subthreshold for the diagnosis.
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488 Arch Sex Behav (2010) 39:477–498
Taken together, these data suggest that, even within a pop- say that he wants to get rid of his penis?’’). Each item was rated
ulation of gender-referred children, the DSM criteria, when on a 3-point response scale (No, Sometimes, or Yes) using the
used categorically (threshold versus subthreshold), signifi- past 12 months as a time frame.
cantly differentiate the behavior of the subgroups on external Because these data are novel and because they may provide
measures. There are, however, limitations to these kinds of leads in potential field trials, I provide the questionnaire in Ap-
analyses that should be acknowledged. For example, differ- pendix. Table 4 shows item level descriptive statistics as a func-
ent combinations of the Point A and Point B criteria could tion of group. At the item level, a preliminary analysis showed
(and probably did) result in a child meeting the complete no significant difference on any of the items between the two
criteria for GID (e.g., such combinations could include control groups. Table 5 shows, for each item, the results of chi-
children who met A1 through A5 versus A2–A5 or even A1 square analyses that compared the GID group with the two
and one of three combinations of A2–A5). As well, these control groups. Columns 3–4 show the results in which the re-
studies did not report how many indicators of the criteria were sponse option of No was compared to the response options of
met for the children who were judged subthreshold for the Sometimes or Yes combined. Of the 31 items, there were 17
diagnosis. Nonetheless, the fact that in these various studies significant group effects, all of which showed greater endorse-
the subthreshold cases fall in-between that of the threshold ment of body image concerns in the GID group. Some of the
cases and controls on external measures is exactly what one significant contrasts pertained to general body image concerns
would have predicted (cf. Bartlett et al., 2000). and others pertained to gender-specific anatomic dysphoria. For
example, regarding Item 5 (‘‘Does he say that he is ugly?’’), 42%
Anatomic Dysphoria of the mothers of GID boys endorsed either a Sometimes or a Yes
response, compared to 15% of the mothers of the control boys
In adolescents and adults with GID, discomfort with the external, (p = .014). Regarding Item 9 (‘‘Does he say that he wants to get
somatic indicators of one’s phenotypic biological sex (both pri- rid of his penis?’’), 13% of the mothers of GID boys endorsed
mary and secondary sex characteristics) are particularly salient either a Sometimes or a Yes response, compared to 0% of the
with regard to the client’s felt sense of gender dysphoria. In some mothers of control boys (p = .046). Similarly, regarding Item 6
respects, this is the sine qua non of the developmental end-state (‘‘Does he say that he would like breasts?’’), 16% of the mothers
of gender dysphoria. Much less is known about the salience of of GID boys endorsed either a Sometimes or a Yes response,
anatomic dysphoria in children with GID (Coates, 1985; Loth- compared to 0% of the mothers of the control boys (p = .016).
stein, 1992). Other than one general item on the GIQC that per- Other items, however, pertaining to gender-specific anatomic
tains to anatomic dysphoria (Johnson et al., 2004), I am not aware dysphoria showed no significant differences among the three
of any other published empirical data on putative indicators of this groups (e.g., Item 16: ‘‘Does he pretend that he has a vagina?’’).
construct. This represents a significant gap in validity research A principal axis factor analysis with varimax rotation iden-
pertaining to the DSM criteria for GID in children. tified 12 items on the ASS that loaded on a general body image
Lambert (2009) assessed body image in 28 boys with GID, factor and 8 items that loaded on a gender-specific anatomic
23 clinical control boys, and 25 non-referred boys (M age, dysphoria factor. Unit-weighted factor scores significantly dif-
8.34 years; SD = 2.52).5 The boys completed two self-report ferentiated the GID boys from the control boys. For the general
measures pertaining to general body image satisfaction. On the body image factor, Cohen’s d = 1.56 and for the gender-spe-
Body Esteem Scale for Children (BES), the GID boys endorsed, cific anatomic dysphoria factor, Cohen’s d = 3.92, using the
on average, significantly more body dissatisfaction than the SD of the control group.
non-referred boys (p \ .05). The mean BES scores of the clin- Although preliminary, these data, particularly at the item
ical control boys did not differ significantly from either the GID level, may provide leads for further investigation in field trials
group or the non-referred group. On the Physical Feature Sat- regarding potential markers of gender-specific anatomic dys-
isfaction Scale (PFSS), there was a borderline main effect for phoria in children.
group. The GID boys endorsed significantly less body part
satisfaction than the non-referred group. The mean PFSS scores Distress and Impairment
of the clinical control boys did not differ significantly from
either the GID group or the non-referred group. Critics who reject the GID diagnosis in toto have adopted
Lambert (2009) also administered to the mothers of the three alternative language to label children who display various de-
groups a 31–item Anatomic Satisfaction Scale (ASS). At the grees of cross-gender behavior and identity. One such label is to
level of content or face validity, items were intended to reflect characterize such children as ‘‘gender nonconforming’’ (Pick-
either general body image issues (e.g., ‘‘Does he say that he is stone-Taylor, 2003); another label that has received a fair bit
ugly?’’) or gender-specific anatomic dysphoria (e.g., ‘‘Does he of recent currency is to characterize them as ‘‘gender variant’’
(Lev, 2004; Menvielle, Tuerk, & Perrin, 2005). The Oxford
5
These data come from a doctoral dissertation that I supervised. Dictionary defines variant as ‘‘a form or version that varies from
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Arch Sex Behav (2010) 39:477–498 489
other forms of the same thing.’’ Variation is defined as ‘‘a change the core of distress, particularly in young children. In my
or slight difference in condition, amount, or level.’’ Variance is opinion, the construct of distress is probably better understood,
defined as ‘‘the amount by which something changes or is dif- at least at the surface level, in relation to a child’s verbalized
ferent from something else.’’ sense of unhappiness about being a boy or a girl, as expressed
By definition, then, it is descriptively accurate to characterize most concretely by remarks about wanting to be of the other sex.
children who meet the GID criteria as they are currently for- Regarding the clinical significance criterion (Table 3), it re-
mulated as gender-variant (indeed, any child whose behavior or mains unclear how distress is to be inferred independently of the
identity departs from some hypothetical mean gold standard clinical indicators in Criterion A and Criterion B. I will note here
could be characterized as gender variant). The deeper philo- that this is a conceptual problem that is not unique to GID. For
sophical (and, perhaps, empirical) debate is whether or not one example, the same problem is present for the diagnosis of
can demarcate a distinction between variance and disorder. Separation Anxiety Disorder in children.
Three decades ago, Meyer-Bahlburg (1985) characterized this Regarding impairment, the DSM-IV refers to difficulties
distinction as the ‘‘zone of transition between clinically signif- in social, occupational, or other important areas of function-
icant cross-gender behavior and mere statistical deviations from ing. For some DSM diagnoses, evidence for impairment can
the gender norm’’ (p. 682). be relatively easy to infer (e.g., a person with a dysthymic
Distress and impairment have come to occupy a critical disorder who is unable to work). In other instances, impair-
position in the DSM. Originally, these constructs were used to ment appears to be less clearly distinguishable from the clin-
formulate a working definition of mental disorder for the DSM- ical signs of disorder, as in the case of Conduct Disorder.
III (see Spitzer & Endicott, 1978), to set some kind of boundary Regarding impairment and GID, one line of evidence
between disorder and variation from the norm. As noted earlier, might be to consider the presence of associated psychopa-
these constructs became part of the diagnostic criteria for about thology (for a brief review, see Lawrence, 2008, pp. 437–
half of the DSM-IV diagnoses, in what has been called the 439). If, for example, adolescents and adults have elevated
clinical significance criterion. As I understand it, one reason this rates of ‘‘other’’ forms of psychopathology, does this consti-
occurred was because there was a concern that the prevalence tute evidence for impairment? On this point, there are dif-
of some disorders as identified in epidemiological studies ap- ferent views. For example, is the associated psychopathology
peared to be ‘‘too high’’ and some researchers could document a result of the distress that accompanies GID (and its atten-
that prevalence was reduced if an impairment or distress crite- dant impact on psychosocial well-being) or is it simply sec-
rion was required (for children, see, e.g., Canino et al., 2004). ondary to the experience of social ostracism (see, e.g., Nutt-
Regarding the distress/impairment criterion for GID, there are brock et al., 2009; Zucker, 2008a)? If it is the result of the
two key issues: (1) How should these constructs be assessed? (2) latter, then it would be arguable to consider this as satisfying
Is the source of the distress or impairment ‘‘in the person’’ or is it an ‘‘in-the-person’’ definition of impairment.
simply secondary to social ostracism? Regarding the latter, critics The same interpretive matters apply to children with GID
of the diagnosis (op. cit.) have largely favored the latter inter- (Zucker, 2008a). There is reasonable evidence that children
pretation (for a further discussion of this, see Zucker, 2005b). with GID have, on average, higher rates of behavior problems
If one considers the developmental end-state of GID, i.e., compared to non-referred children (Cohen-Kettenis et al.,
its mature form as expressed during adolescence and adult- 2003; Zucker, 2008a; Zucker & Bradley, 1995). It has been
hood, I would argue that distress is manifested most acutely in demonstrated that such associated psychopathology can be
the form of the disjunction between the client’s felt psycho- predicted, in part, by social ostracism parameters (Cohen-
logical gender identity and phenotypic sex (in children, per Kettenis et al., 2003). Thus, it could be argued, quite rea-
their awareness that they have an ‘‘assigned’’ sex). Many sonably, that this form of impairment is a by-product of
years ago, Fisk (1973) coined the term gender dysphoria to stigma and not ‘‘in-the-person’’ per se. On the other hand, the
characterize the sense of awkwardness or discomfort in the DSM is not entirely clear with regard to the phrase ‘‘[t]he
anatomically congruent gender role and the desire to possess disturbance causes clinically significant distress or impair-
the body of the other sex, together with the negative affect ment in social, occupational, or other important areas of
associated with these feelings and desires. Clinically, it has functioning’’ (my emphasis) (on this point, see also Bartlett
been used to refer to the range of individuals who, at one time et al., 2000). One could, for example, argue that the behaviors
or another, experience sufficient discomfort with their as- associated with GID ‘‘cause’’ impairment because of social
signed sex to form the wish for sex reassignment. It is this ostracism, but I am not sure that this is what the DSM intends
disjunction that often leads clients to seek out clinical care in its conceptual formulation of impairment.
and treatment. As an aside, it should be pointed out that efforts to measure
Although children with GID may experience some sense of impairment, in general, are vulnerable to similar difficulties
discomfort with their sexual anatomy, as suggested by Lam- in interpretation. Consider, for example, items used to mea-
bert’s (2009) data, it is unlikely that this anatomic dysphoria is at sure impairment by Canino et al. (2004): How much of a
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490 Arch Sex Behav (2010) 39:477–498
Table 4 Descriptive statistics (in percent) for each item on the Anatomic Satisfaction Scale as a function of group
Item GID Clinical control Community control
No Sometimes Yes No Sometimes Yes No Sometimes Yes
N % N % N % N % N % N % N % N % N %
1 11 36 5 16 15 48 14 61 3 13 6 26 19 76 2 8 4 16
2 22 71 5 16 4 13 13 57 1 4 9 39 9 36 2 8 14 56
3 27 87 2 7 2 7 23 100 0 0 0 0 24 96 0 0 1 4
4 30 97 0 0 1 3 23 100 0 0 0 0 24 96 1 4 0 0
5 18 58 6 19 7 23 19 83 2 9 2 9 22 88 3 12 0 0
6 26 84 3 10 2 7 23 100 0 0 0 0 25 100 0 0 0 0
7 21 68 9 29 1 3 19 83 4 17 0 0 21 84 4 16 0 0
8 17 55 5 16 9 29 22 96 0 0 1 4 25 100 0 0 0 0
9 27 87 2 7 2 7 23 100 0 0 0 0 25 100 0 0 0 0
10 24 77 2 7 5 16 20 87 1 4 2 9 21 84 2 8 2 8
11 27 87 3 10 1 3 10 44 4 17 9 39 16 64 4 16 5 20
12 5 16 5 16 21 68 4 17 4 17 15 65 6 24 6 24 13 52
13 22 71 3 10 6 19 18 78 1 4 4 17 22 88 0 0 3 12
14 31 100 0 0 0 0 23 100 0 0 0 0 23 92 1 1 1 1
15 24 77 3 10 4 13 22 96 0 0 1 4 25 100 0 0 0 0
16 30 97 1 3 0 0 23 100 0 0 0 0 24 96 1 4 0 0
17 28 90 1 3 2 7 23 100 0 0 0 0 25 100 0 0 0 0
18 27 87 4 13 0 0 21 91 1 4 1 4 24 96 1 4 0 0
19 28 90 2 7 1 3 21 91 1 4 1 4 22 88 3 12 0 0
20 23 74 5 16 3 10 22 96 1 4 0 0 25 100 0 0 0 0
21 29 94 1 3 1 3 17 74 4 17 2 9 18 72 1 4 6 24
22 19 61 5 16 7 23 22 96 0 0 1 4 24 96 1 4 0 0
23 25 81 1 3 5 16 21 91 1 4 1 4 25 100 0 0 0 0
24 19 61 5 16 7 23 19 83 3 13 1 4 23 92 2 8 0 0
25 3 10 8 26 20 65 2 9 1 4 20 87 2 8 1 4 22 88
26 20 65 5 16 6 19 19 83 2 9 2 9 21 84 3 12 1 4
27 27 87 3 10 1 3 22 96 0 0 1 4 23 92 1 4 1 4
28 25 81 2 7 4 13 13 57 2 9 8 95 13 52 6 24 6 24
29 11 36 9 29 11 36 16 70 6 26 1 4 22 88 2 8 1 4
30 19 61 5 16 7 23 15 65 7 30 1 4 20 80 2 8 3 12
31 20 65 7 23 4 13 23 100 0 0 0 0 23 92 1 4 1 4
Note: Data from Lambert (2009)
problem does he/she have: (1) with feeling nervous or afraid? Harmonizing Descriptors
(2) getting along with his/her brothers/sisters? (3) getting
along with other kids his/her age? (4) getting along with you In the DSM, various adverbs or adjectives are used to em-
[the mother]? (5) getting along with his/her father? (6) feeling phasize for the clinician that an indicator or symptom rep-
unhappy or sad? In all instances, it is not entirely clear if resents an enduring pattern of behavior, not a transitory one.
positive responses to such questions would constitute evi- For the diagnosis of Attention-Deficit/Hyperactivity Disor-
dence for ‘‘in-the-person’’ impairment or as secondary to der, for example, each of 18 possible symptoms is prefaced
social responses to deviant behaviors. by the adverb ‘‘often.’’ The same adverb is used for each of
In summary, the constructs of distress and impairment the 8 possible symptoms of Oppositional Defiant Disorder.
require a great deal of further consideration in terms of how Thus, the clinician only needs to decide what counts as ‘‘of-
they should best be operationalized and measured in children ten.’’ Of course, for these diagnoses, the clinician must also
with GID (and to children in general). make a judgment about what counts as (the lack) of ‘‘close
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Arch Sex Behav (2010) 39:477–498 491
Table 5 Results of chi-square analysis for each item on the ASS as a criterion, in which the child must be judged to have a ‘‘re-
function of group and response choice peatedly’’ stated desire to be, or insistence that he or she is, the
Item No, Sometimes, or Yesa No vs. Sometimes and Yesb other sex. What counts as ‘‘repeatedly’’? On the GIQC Item
13 reported by Johnson et al. (2004), 18.4% of gender-re-
v2 p v2 p
ferred boys and 14.0% of gender-referred girls were rated by
1 8.75 .013 7.15 .007 their mothers as verbalizing the wish to be of the other sex
2 10.71 .005 3.85 .050 ‘‘very rarely.’’ The corresponding percentages for control
3 4.28 ns 2.11 ns boys and girls were 3.3% and 5.6%, respectively. It is likely
4 2.20 ns \1 ns that a clinician would not judge a ‘‘very rarely’’ response to
5 8.57 .014 6.07 .014 be commensurate with ‘‘repeatedly.’’ In contrast, 22.1% of
6 8.27 .016 5.76 .016 gender-referred boys and 44.0% of gender-referred girls
7 3.48 ns 1.79 ns were rated by their mothers as verbalizing the wish to be of the
8 22.83 .001 20.00 .001 other sex ‘‘frequently’’ or ‘‘every day’’ in contrast to 0% of
9 6.52 .038 4.11 .046 control boys and girls. One would suspect that such ratings
10 1.15 .562 \1 ns would be deemed commensurate with the ‘‘repeatedly’’ de-
11 10.38 .006 7.81 .005 scriptor. But what about the intermediate response option of
12 \1 ns \1 ns ‘‘once-in-a-while’’? This option was selected by 36.4% of the
13 2.77 .250 1.05 ns mothers of the gender-referred boys and 26.0% of the moth-
14 1.33 .516 \1 ns ers of gender-referred girls; in contrast, only 1.7% of the
15 9.01 .011 6.58 .010 mothers of the control boys and 2.0% of the mothers of the
16 \1 ns \1 ns
control girls selected this option. It is not entirely clear what
17 4.83 .089 2.54 ns
‘‘once-in-a-while’’ exactly means, but if the desire to be of the
other sex is expressed on a once-in-a-while basis over, say, a
18 2.63 ns \1 ns
6-month period, does this count as repeatedly?
19 \1 ns \1 ns
20 10.73 .005 8.28 .004
21 5.26 .072 3.95 .047
22 15.44 .001 13.13 .001 Recommendations
23 5.47 .065 3.25 .071
24 9.98 .007 5.94 .015 In this section, I advance three diagnostic options for con-
25 8.27 .016 \1 ns sideration by the DSM-V Sexual and Gender Identity Dis-
26 4.20 ns 2.69 ns orders Workgroup.
27 2.28 ns \1 ns
28 5.79 .055 4.67 .031 Option 1
29 18.36 .001 13.46 .001
30 3.19 ns \1 ns The first option would be to leave the criteria as they currently
31 13.51 .001 11.25 .001 stand, other than consideration of some changes in wording
Note: Data from Lambert (2009) (e.g., even greater harmonization in the criteria for boys and
a
Three response choices girls). An argument in favor of this option is that the current
b
Two response choices criteria have behaved reasonably well; for example, they
show evidence of discriminant validity and, at least using the
gold standard of clinician diagnosis, appear to reasonably
attention,’’ ‘‘difficulty sustaining attention’’ or ‘‘careless’’ distinguish between threshold and subthreshold cases. In my
mistakes, etc., which is a somewhat different matter. view, the main argument against retaining the criteria as they
In the case of GID, various qualifiers are employed (e.g., currently stand is that the ability to make the diagnosis in the
‘‘repeatedly,’’ ‘‘insistence,’’ ‘‘strong and persistent,’’ ‘‘in- absence of repeated verbal statements that one wishes to be of
tense,’’ ‘‘strong,’’ ‘‘marked,’’ etc.). It is not entirely clear why, the other sex has led to confusion and the concern that the
in the DSM-IV, these variations on the same theme were diagnosis is capturing children who are merely ‘‘gender
employed and if such semantic nuance weakens reliability in variant.’’ Although I do not believe that this was the intent of
clinician judgment. There is, of course, also the translational the DSM-IV Subcommittee on Gender Identity Disorders,
problem for the clinician in deciding on what counts as the concern about the A1 criterion runs across many of the
‘‘repeatedly,’’ ‘‘strong,’’ etc. Consider, for example, the A1 critiques of the diagnosis as currently formulated.
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Option 2 Table 6 Proposed revision to the DSM-IV diagnostic criteria for

Gender Identity Disorder in Children
The second option would be to tighten the criteria by chang- A. A strong discomfort with one’s gender identity (in relation to the
ing the Point A criterion to include all five parameters (A1– assigned sex at birth), of at least 6 months duration, as manifested by
A5) as they are currently formulated in the DSM-IV. Inclu- at least six of the following indicators (including A1)
sion of the verbalized desire to be of the other sex would make (1) a frequently stated desire to be the other sex or a frequently stated
insistence that he or she is the other sex
the diagnosis more transparent in its aim to identify chil-
(2) in boys, a strong preference for cross-dressing or simulating female
dren who are, without ambiguity, struggling with their gender
attire; in girls, a strong preference for wearing only stereotypical
identity (see, e.g., de Vries & Cohen-Kettenis, 2009). The masculine clothing and a strong rejection in the wearing of
analyses that I reported on above clearly show that children culturally normative feminine clothing
who more frequently state the desire to be of the other sex (by (3) a strong preference for cross-sex roles in make-believe or fantasy
maternal report) also show more cross-gender surface behav- play
ior. Inclusion of A1 would likely constrict the net of chil- (4) a strong preference for the stereotypical toys, games, or activities of
dren judged to meet the criteria for GID and this might be the other sex
received by critics as responsive to concerns about misdi- (5) a strong preference for playmates of the other sex
agnosis or overdiagnosis (even if this concern is incorrect). (6) in boys, a strong rejection of stereotypical masculine toys, games,
and activities and a strong avoidance of rough-and-tumble play; in
A counter argument to this perspective is that children who girls, a strong rejection of stereotypical feminine toys, games, and
meet the A2–A5 criteria and the B criterion may actually be activities
struggling with their gender identity (for a clinical example, (7) a frequently stated or behaviorally represented dislike of one’s
see Zucker, 2004). It has been suggested by some clinicians sexual anatomy; in boys, manifested by one of the following: that
that there are children who may harbor a strong desire to be he would like to have a vagina or to grow breasts; that he dislikes his
penis or testes; simulation of female genitalia by sitting to urinate;
of the other sex, but do not verbalize it because of a coercive in girls, manifested by one of the following: that she would like to
social environment (H. F. L. Meyer-Bahlburg, personal com- have a penis or to grow one; that she dislikes the prospects of breast
munication, May 26, 2009). If they do not receive a diagnosis, development or that she has a vagina; simulation of male genitalia
it may influence treatment options that ultimately might not by standing to urinate
be in the best interest of the child. One solution to this would B. The disturbance is not concurrent with a physical intersex condition
be to use the residual diagnosis of GIDNOS, along with C. The disturbance causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning
modification to the text that describes the clinical complexity
in making a diagnosis, particularly for those children who, for Note: These proposed revisions represent my suggestions at the time I
whatever reason, do not verbally express their underlying completed this review (December 29, 2008) for the Sexual and Gender
Identity Disorders Work Group. They should not be read as reflecting
gender dysphoria. any type of final consensus on the part of the Gender Identity Disorders
subworkgroup
Option 3
A third, more radical option would be to eliminate from the psychometrics. Field trials could thus focus on establishing
criteria set all of the surface behaviors of possible cross-gen- the much-needed evidence of inter-clinician agreement in
der identity and relegate them to the text description of the diagnosis and rely on already well-developed psychometric
diagnosis (e.g., Associated Descriptive Features). Here, one measures of external validity.
could point out that although these behaviors are often part of In Table 6, I provide a proposal for a revised criteria set
the GID phenomenology, they are also present among chil- that includes 7 indicators, which represent a combination
dren who show pervasive cross-gender behavior but do not of the A and B criteria in DSM-IV. It specifies that the desire
experience distress or unhappiness about their gender iden- to be of the other sex is necessary for the diagnosis to be giv-
tity. In their place, one could recommend a largely new set en. The criteria are written in a manner that uses one of two
of diagnostic criteria that focus more directly on different consistent qualifiers (‘‘frequently’’ or ‘‘strong’’) across indi-
manifestations of gender dysphoria. cators. In addition, I suggest a lower-bound duration criterion
I favor Option 2. Option 2 would represent a reasonable of 6 months. The GID diagnosis has never had a formal
response to criticisms of the criteria as currently formulated. duration criterion, unlike many other psychiatric diagnoses
It would, if anything, reduce the number of children who meet for children (e.g., 1 month: Selective Mutism; 4 weeks: Sep-
the criteria for GID. It would build on a history of studies that aration Anxiety Disorder [SAD]; 6 months: Attention-Defi-
have already established reasonable evidence for the dis- cit/Hyperactivity Disorder, Generalized Anxiety Disorder,
criminant validity of the diagnosis and even some evidence of and Oppositional Defiant Disorder [ODD]; 12 months: CD).
predictive validity (per Wallien & Cohen-Kettenis, 2008). Whereas there was good empirical evidence to justify the
Field trials would not have to start from scratch in terms of duration criterion for CD (Lahey et al., 1998), this was less
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Arch Sex Behav (2010) 39:477–498 493
so the case, for example, for SAD and the duration criterion 2008; Zucker, 2008b). But the reasons for prospective dis-
was modeled on the ICD-10 definition and an older empirical continuity are likely to be mulifactorial and, in and of itself,
literature (Klein, Tancer, & Werry, 1997). there is no compelling reason to contest in toto the relation
For GID, there is no formal empirical evidence for set- between GID in childhood versus adolescence and adult-
ting a specific lower-bound for duration, but this could, con- hood. Indeed, the disjunction between retrospective and pro-
ceivably, be examined in a field trial. Clinically, with the spective continuity shares a similarity to the same kind of
exception of very young children (in the age range of 2– disjunction for CD and ODD (see Lahey, Loeber, Quay,
4 years), it is very common for the putative symptoms of GID Frick, & Grimm, 1997): classical CD is almost always pre-
to have been of substantial duration, as parents often do not ceded by ODD whereas the majority of children with ODD
seek out an evaluation until they, or a health professional, followed prospectively do not develop CD (see also Nock,
deem the behavior ‘‘no longer a phase’’ (see Zucker, 2000). Kazdin, Hiripi, & Kessler, 2007).
The inclusion of a specific duration criterion would have Over the years, there have been a myriad of terms used to
the advantage of alerting the clinician to be attentive to chro- label the phenomenology that is represented by the diagnostic
nicity and to be sensitive to instances of cross-gender be- label of GID. If GID is to remain in the DSM-V, should it retain
havior/identity that are transitory, perhaps in response to an the same name or should alternatives be considered? Di Ceglie
acute or isolated stressor (e.g., the birth of a younger sibling) (1998) has used the term Atypical Gender Identity Organiza-
(Coates & Zucker, 1988). tion to ‘‘define an internal psychological configuration whose
phenomenology is represented by the typical characteristics
Cultural Considerations of a gender identity disorder’’ (p. 9). Vitale (2001) suggested
the term Gender Expression Deprivation Anxiety Disorder,
For DSM-V, there will likely be greater attention given to the arguing that GID ‘‘may for treatment purposes be better de-
interface between culture and psychopathology (Alarcón et al., scribed as a chronic anxiety disorder’’ (p. 121).
2002). There is certainly now a great deal of evidence to suggest Others have suggested that the inclusion of the word ‘‘Dis-
that there are ‘‘non-Western’’ equivalents to GID in many dif- order’’ in GID adds to the burden of stigma (see Meyer-Bahl-
ferent cultures and countries, both in children and in adults (see, burg, 2009). As an alternative, for example, Bancroft (2009),
e.g., Bartlett & Vasey, 2006; Newman, 2002; Tucker & Keil, suggested the term ‘‘gender identity discordance’’ (p. 291).
2001; Vasey & Bartlett, 2007). If cultural features are added to On the matter of naming, I have no strong recommenda-
the DSM-V, it will be important to consider the applicability of tion other than to consider the rule of parsimony. In DSM-IV,
the GID criteria, particularly in non-Western cultures. most diagnoses contain the word ‘‘Disorder,’’ but not all (e.g.,
Pica, Enuresis, Encopresis, Major Depressive Episode, An-
Diagnostic Terminology orexia Nervosa, Bulimia Nervosa, all of the Paraphilias, etc.).
For DSM-IV, the Subcommittee on Gender Identity Disorders

(Bradley et al., 1991) recommended that Gender Identity Dis- Secondary Data Analysis and Field Trials
order be used as an overarching term (collapsing the diagnoses
of GIDC, Transsexualism, and GIDAANT from DSM-III-R). Recommendations for secondary data analysis and field trials
In part, this was argued because the term transsexualism was, are as follows:
at least in some circles, equated with a specific form of thera-
peutics, namely, contra-sex hormonal and surgical treatment. In 1. The re-analyses that I conducted on the GIQC can be
addition, it was argued that GID in childhood versus adoles- examined in the cohort of child gender patients seen at
cence and adulthood were, in effect, the same condition, but the Amsterdam Gender Clinic, as both the GIQC and the
expressed differently as a function of developmental level. GII are part of the Dutch assessment protocol. Secondary
Regarding the latter point, there is evidence for and against data analysis of the Dutch clinic data can provide a test of
this argument. On the one hand, there is reasonable evidence the consistency of the results reported here.
for retrospective continuity, particularly when one examines 2. If the Gender Identity Disorders subworkgroup agrees on
the developmental histories of adolescents and adults who the merit of conducting field trials on a set of revised
have a sexual orientation (attraction) to members of their criteria, these should be studied on new clients seen in
birth sex (see, e.g., Singh et al., 2009; Zucker, 2006b). On the my own clinic and in the Amsterdam Gender Clinic. The
other hand, the evidence for prospective continuity is weaker, subworkgroup should identify a target sample size for
but still substantial if one relies on crude estimates of GID the probands and to collect clinical control data on a
prevalence in adults (Drummond, Bradley, Peterson-Badali, comparable sample size. The feasibility should be ex-
& Zucker, 2008; Green, 1987; Wallien & Cohen-Kettenis, plored of enlisting other clinicians who assess children
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494 Arch Sex Behav (2010) 39:477–498
with gender problems to test a revised set of criteria. The 2. Identification of psychometric measures that match the
aim of the field trial would be to establish inter-clinician reformulated diagnostic criteria.
reliability and to conduct tests of discriminant validity.
Acknowledgments This review was prepared for the DSM-V Sexual
Dimensional Diagnosis and Gender Identity Disorders Work Group. I would like to thank the
following individuals who provided feedback on the paper: Ray Blan-
The subworkgroup needs to explore possible methods for chard, Peggy T. Cohen-Kettenis, Domenico di Ceglie, Jack Drescher,
Heino F. L. Meyer-Bahlburg, Friedemann Pfäfflin, and Devita Singh.
dimensional diagnosis. In my view, these could include at Elements of the paper were presented at the Annual Meeting of the
least two parameters: Society for Sex Therapy and Research in Arlington, VA, April 2–5,
2009. Reprinted with permission from the Diagnostic and Statistical
1. A symptom count based on a polythetic approach to Manual of Mental Disorders V Workgroup Reports (Copyright 2009),
categorical diagnosis. American Psychiatric Association.
Appendix
Anatomic Satisfaction Scale: Parent Report (ASS). Instructions: The like this, NO, if your child is not like this, or SOMETIMES if you think
following questions are about your child now or within the past year. your child is somewhat like this
Please answer each question by checking YES if you think your child is
Yes Sometimes No
1. Does _____ say that he wished he could change something about the way that he looked? If yes, what?
2. Does _____ say that he likes his body?
3. Does _____ say that he would like a vagina?
4. Does _____ say that he dislikes his penis?
5. Does _____ say that he is ugly?
6. Does _____ say that he would like breasts?
7. Does _____ pretend that he is pregnant (e.g., does he stuff his shirt)?
8. Does _____ say that he wished he looked like a girl?
9. Does _____ say that he wants to get rid of his penis?
10. Does _____ express dislike for body hair, facial hair, or hair growth on any place aside from his head?
11. Does _____ say he is proud of his body?
12. Does _____ like to look at himself in the mirror?
13. Does _____ think that he is overweight?
14. Does _____ worry about the size of his penis?
15. Does _____ talk about wanting to shave his legs when he is older?
16. Does _____ pretend that he has a vagina?
17. Does _____ say that he wishes his face were prettier?
18. Does _____ pretend that he doesn’t have a penis?
19. Does _____ complain about his penis getting larger (e.g., when it gets erect)?
20. Does _____ ever say that he wants surgery to change something about himself?
21. Does _____ say that he wishes he were bigger (physically)?
22. Does _____ pretend that he has breasts?
23. Does _____ say that he wishes he were smaller (physically?)
24. Does _____ fixate on a physical feature that he doesn’t like about himself?
25. Does _____ like what he looks like in pictures?
26. Does _____ wish he were thinner?
27. Does _____ pretend to shave his legs (or another part of his body?)
28. Does _____ wish he had bigger muscles?
29. Does _____ worry about the way that he looks?
30. Does _____ wish he looked like someone else? If yes, who?
31. Do _____’s looks upset him?
Note: From Lambert (2009)
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Arch Sex Behav (2010) 39:477–498 495
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DOI 10.1007/s10508-009-9562-y
ORIGINAL PAPER
The DSM Diagnostic Criteria for Gender Identity Disorder

in Adolescents and Adults
Peggy T. Cohen-Kettenis • Friedemann Pfäfflin

Abstract Apart from some general issues related to the Keywords Gender identity disorder Transsexualism
Gender Identity Disorder (GID) diagnosis, such as whether Gender dysphoria DSM-V
it should stay in the DSM-V or not, a number of problems
specifically relate to the current criteria of the GID diagnosis
for adolescents and adults. These problems concern the con-
fusion caused by similarities and differences of the terms Introduction
transsexualism and GID, the inability of the current criteria to
capture the whole spectrum of gender variance phenomena, Transsexualism first appeared as a diagnosis in the third edi-
the potential risk of unnecessary physically invasive exam- tion of the Diagnostic and Statistical Manual of Mental Dis-
inations to rule out intersex conditions (disorders of sex de- orders (DSM-III) (American Psychiatric Association, 1980).
velopment), the necessity of the D criterion (distress and Besides transsexualism, a separate diagnosis of Gender Iden-
impairment), and the fact that the diagnosis still applies to tity Disorder of Childhood was also introduced. Instead of
those who already had hormonal and surgical treatment. If the classifying transsexualism as an Axis I diagnosis within the
diagnosis should not be deleted from the DSM, most of the chapter Psychosexual Disorders, DSM-III-R (American Psy-
criticism could be addressed in the DSM-V if the diagnosis chiatric Association, 1987) classified it as an Axis II disorder,
would be renamed, the criteria would be adjusted in word- i.e., one of the disorders ‘‘typically beginning in infancy, child-
ing, and made more stringent. However, this would imply that hood or adolescence.’’ Also included was a diagnosis Gender
the diagnosis would still be dichotomous and similar to ear- Identity Disorder of Adolescence or Adulthood, Nontranssexual
lier DSM versions. Another option is to follow a more di- Type (GIDAANT) for cross-gender identified individuals who
mensional approach, allowing for different degrees of gender did not pursue sex reassignment. A diagnosis Gender Identity
dysphoria depending on the number of indicators. Consid- Disorder Not Otherwise Specified (GIDNOS) was used for
ering the strong resistance against sexuality related specifiers, those who did not fulfill criteria for the specific gender identity
and the relative difficulty assessing sexual orientation in disorders. In the DSM-IV-TR (American Psychiatric Associa-
individuals pursuing hormonal and surgical interventions to tion, 2000), only one specific diagnosis, Gender Identity Dis-
change physical sex characteristics, it should be investigated order (GID), was included. Here, GID was viewed as basically
whether other potentially relevant specifiers (e.g., onset age) one Axis I disorder that could develop along different routes and
are more appropriate. could have various levels of intensity (Bradley et al., 1991).
The DSM has consistently approached gender problems
from the position that a divergence between the assigned sex
P. T. Cohen-Kettenis (&)
Department of Medical Psychology, VU University Medical or ‘‘the’’ physical sex (assuming that ‘‘physical sex’’ is a one-
Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands dimensional construct) and ‘‘the’’ psychological sex (gender)
e-mail: [email protected] per se signals a psychiatric disorder. Although the termi-
nology and place of the gender identity disorders in the DSM
F. Pfäfflin
Department of Psychosomatic Medicine and Psychotherapy, have varied in the different versions, the distress about one’s
University of Ulm, Ulm, Germany assigned sex has remained, since DSM-III, the core feature of
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the diagnosis. The DSM has also always made a distinction of the ICD-10, F64.0, which bear a close resemblance to the
between GID in childhood, adolescence and adulthood, and DSM-IV-TR criteria. In the first decade of the application of
the category GIDNOS. the German Law for Transsexuals, more than a 1,000 cases
In this article, we will review problems and criticisms with have been processed by the courts (Weitze & Osburg, 1998).
the current DSM criteria for GID in post-pubertal individuals. Very rarely, the court had to ask for a third, independent
The debate on whether GID should remain in the DSM (e.g., expert opinion or to make its decision without consulting a
Winters, 2005) is a different one and will be discussed else- third expert, because the two independent experts did not
where by Meyer-Bahlburg (2009). Here, we assume that a agree in their evaluation (Pfäfflin, 2009; Weitze & Osburg,
diagnosis related to atypical gender identity will not be re- 1998).
moved from the DSM. We will not focus on the meta-structure Validity of the DSM diagnosis can, perhaps, also be in-
of the DSM diagnoses either, as this will also be addressed by ferred from studies that have been conducted to evaluate sex
Meyer-Bahlburg (2009). In our review, we will discuss criteria reassignment as a treatment procedure (see Pfäfflin & Junge,
for both adolescents and adults. The current criteria are the same 1992, 1998 for studies until 1990; Gijs & Brewaeys, 2007 for
for the two age groups, and there are very few studies on ado- studies between 1990 and 2007). Since the publication of the
lescents with GID only. Whenever appropriate, we will address DSM-IV in 1994, five of these follow-up studies explicitly
adolescent issues separately. mention the use of DSM diagnoses (Bodlund & Kullgren,
This review is based on the research literature, informa- 1996, Lawrence, 2003; Lobato et al., 2006; Rakic, Starcevic,
tion coming from transgender communities (Vance et al., in Maric, & Kelin, 1996; Smith, van Goozen, Kuiper, & Cohen-
press), and clinical experience of the authors until June 2009. Kettenis, 2005). In these studies, the mean follow-up period
It does not reflect the discussions and subsequent decisions of ranged from 12 to 60 months; 976 participants were ap-
the DSM-V subworkgroup on GID, leading to the final rec- proached and 428 participated in the follow-up studies, a
ommendations of the workgroup to the APA. response rate of about 50%. In about 3%, unsatisfactory re-
sults were reported. It should be noted that an ‘‘unsatisfactory
result’’ does not necessarily imply post-operative regret
about the sex reassignment or a wish to live in the original
Reliability and Validity of the Current Criteria gender role again (Kuiper & Cohen-Kettenis, 1998). Some
participants in follow-up studies were just very dissatisfied
Important in the decision to maintain a distinct diagnosis is with the surgical complications, unhappy about losses in their
the question whether or not the diagnosis can be made reli- lives (family, friends), or experienced little acceptance in
ably, that is, whether different clinicians assessing the same their social environments. However, even if all unsatisfac-
persons will come to the same diagnoses. As noted earlier, tory results are included, sex reassignments based on DSM
this is especially important for the diagnosis of GID, because diagnoses primarily resulted in satisfying results, in terms of
one of the most drastic medical treatments, sex reassignment alleviating the discomfort about one’s sex or the ‘‘gender
surgery, may ensue from this diagnosis. Unfortunately, in the dysphoria.’’ Although diagnosis and response to sex reas-
clinical research literature on adolescents and adults, such signment are not very closely connected, and the reported
inter-rater reliability studies have not been done. Also, no findings are certainly no ‘‘proof’’ of the correctness of the
structured interviews assessing DSM-IV-TR GID and GID- diagnosis, they suggest that the elements of the DSM diag-
NOS diagnoses have been developed, and no comparisons nosis are clinically useful. This not only applies to the DSM-
have been made between clinical diagnoses and diagnoses IV-TR criteria, but also to the earlier DSM diagnoses, be-
based on structured interviews. This means that there is also a cause studies prior to 1990 have shown similar results
lack of formal validity studies in this area. However, with (Pfäfflin & Junge, 1992, 1998). The conclusion has to be
regard to the diagnosis of transsexualism according to the drawn with reservation, though, because it is conceivable that
ICD-10 (World Health Organization, 1992), there is some non-participants in follow-up studies were misdiagnosed.
evidence for diagnostic reliability. According to the German Core aspects of GID (gender dysphoria and gender iden-
Law for Transsexuals (1980, Bundesgesetzblatt I, 1654), in tity) have also been measured in a dimensional way. Since the
force since January 1, 1981, all applicants for a legal change publication of the DSM-IV, these included the Gender Dys-
of their Christian name (independent of sex reassignment phoria Interview and the Gender Dysphoria/Identification
surgery) and/or for a legal change of the personal status as Questionnaire reported on by Zucker et al. (1996), the Gender
male or female (after sex reassignment surgery) have to be Identity/Gender Dysphoria Questionnaire for Adolescents
assessed by two independent experts, before the court will and Adults (GIDYQ-AA) by Deogracias et al. (2007) and
rule on such changes. The experts have to confirm the diag- Singh et al. (2009), and the Utrecht Gender Dysphoria Scale
nosis of transsexualism according to the diagnostic criteria (UGDS) by Cohen-Kettenis and van Goozen (1997). The first
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instrument was used in a study on women with congenital libido and allowing them to feel more at ease (Hertoft &
adrenal hyperplasia (CAH), but no data were reported on Sörensen, 1979). Only afterwards, when the case became pub-
persons attending gender identity clinics. The reliabilities of lic, did the team accept the results as a ‘‘sex change.’’ The treat-
the GIDYQ-AA and UGDS are high: a Cronbach’s alpha for ment created not only sensational stories in the public press, but
the GIDYQ-AA of .97, and for the UGDS of .66–.80 in one also criticism from psychiatric circles (Meyerowitz, 2002; Os-
sample, and .78–.92 in another. The lower alphas on the trow, 1953; Wiedeman, 1953). The treating physician, Ham-
UGDS were only found among control subjects, which may burger, was accused of complying with the patient’s demands
be related to the lower variability of gender dysphoria in these rather than offering psychotherapy to treat the ‘‘sexual perver-
groups. Both instruments showed good discriminant validity, sion.’’ This was the beginning of a still ongoing, territorial
when adolescents and adults with and without a GID diag- struggle between clinical disciplines for the domination of the
nosis were compared. Sensitivity and specificity rates of field. Because, in the early years, there were no official standards
90.4% and 99.7% were reported on the GIDYQ-AA, using a of care issued by a professional organization, (surgical) treat-
cut-point of 3 on a 1–5 point scale. These studies indicate that ment quality differed widely. At the time, neither eligibility re-
gender dysphoria can be reliably and validly measured. How- quirements for sex reassignment nor diagnostic procedures
ever, these instruments are only now beginning to be used in were based on multidisciplinary consensus. Diagnosis and eli-
clinical practice. gibility decisions were not standardized: ‘‘Centers in the Wes-
tern hemisphere offered surgical sex reassignment to persons
having a multiplicity of behavioral diagnoses applied under
Problems with the Current Diagnostic Criteria a multiplicity of criteria’’ (Walker et al., 1985, p. 80). Due to
concern about this unfavorable situation, The Harry Benja-
Apart from more general concerns regarding the GID diag- min International Gender Dysphoria Association (HBIGDA, in
nosis for adults, a number of problems specifically relate to 2009 re-named the World Professional Association for Trans-
the current criteria (Appendix 1). These problems concern (1) gender Health [WPATH]), the first international profession-
the similarities and differences between the terms transsex- al organization in the field, distributed the Standards of Care
ualism and GID, (2) the inability of the current criteria to (SOC) for the treatment of gender dysphoric persons in 1979
capture the spectrum of gender variance phenomena, (3) the (first published by Walker et al., 1985). The aim of these stan-
potential risk of unnecessary physically invasive examina- dards was to set minimal standards for the assessment and de-
tions to ‘‘rule out’’ intersex conditions if the C criterion re- termination of eligibility for hormonal and surgical interven-
mains part of the diagnosis, (4) the necessity of the D criterion tions, thereby providing optimal care (Coleman, 2009). The
for a GID diagnosis, and (5) the fact that the diagnosis still same concern for quality health care and the conviction that psy-
applies to postoperative transsexuals. chiatrists or mental health professionals with sufficient knowl-
edge of psychopathology should make the decision about the
sex reassignment applicant’s eligibility contributed to the inclu-
Similarities and Differences Between the Terms sion of the diagnosis in the DSM-III.
Transsexualism and GID After the introduction of the first published version of
HBIGDA’s SOC (Walker et al., 1985), referral for hormonal
The appearance of the diagnosis ‘‘transsexualism’’ in the DSM- and/or surgical interventions was made dependent on the DSM
III (American Psychiatric Association, 1980) occurred approx- diagnosis of ‘‘transsexualism’’ by those who used the SOC,
imately 50 years after estrogens and androgens became avail- because it was feared that individuals not meeting the criteria
able and after considerable progress had been made in the field would not benefit from the medical interventions and be at risk
of genital surgery and anesthesiology. It had, therefore, become for postoperative regret.
possible for individuals to pass socially and (partially) ana- The previous DSM and ICD diagnoses of ‘‘transsexualism’’
tomically as a member of the other gender in an unprecedented closely linked the diagnosis of transsexualism to hormonal and
way (Bullough, 2007). Reports on Christine Jorgensen, an surgical sex reassignment. The diagnosis was often used as
American who underwent hormonal and partial surgical sex little else than a search for the ‘‘true transsexual,’’ in order to
reassignment from male to female in Denmark (Hamburger, refer the person for hormone and surgical treatment. This use
Strürup, & Dahl-Iversen, 1953), were celebrated upon her return gave rise to the criticism that diagnosis and treatment options
to the U.S. for having had a ‘‘sex change.’’ Initially, neither she were too closely connected. However, the current GID diag-
nor her doctors had intended the ‘‘sex change’’ but wanted to nosis is often still used as if it were identical with the diagnosis
‘‘cure’’ Jorgensen’s ‘‘homosexuality.’’ At the time, homosexu- of transsexualism. For example, in a paper by Sohn and Bos-
als were considered to suffer from an abnormal sex drive, and inski (2007, p. 1193): ‘‘Transsexualism is defined as a strong
castration was seen as a way of helping them to reduce their and persistent cross-gender identification with the patient’s
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persistent discomfort with his or her sex and a sense of inap- diagnosis covers a broad area of conditions comprising much
propriateness in the gender role of that sex …(DSM-IV-TR)’’ more than transsexualism (see below).
(our emphasis). Clinicians who have to make sex reassignment
surgery decisions indeed have the need for a diagnosis spe- The Inability of the Current Criteria to Capture
cifically addressing the seriousness of the condition (Bower, the Spectrum of Gender Variance Phenomena
2001). Although it may be that the current GID diagnosis for
adolescents and adults intended to indicate a condition as se- A second problem with the current criteria is that gender
rious as transsexualism, the criteria are, in fact, somewhat identity, gender role, and gender problems are conceptual-
broader. For instance, the A criterion can be met if only one of ized dichotomously rather than dimensionally. For instance,
the symptoms—‘‘stated desire to be the other sex,’’ ‘‘frequent the accompanying DSM-IV text states that adults with GID
passing as the other sex,’’ ‘‘desire to live or be treated as the are preoccupied with their wish to live as a member of the
other sex,’’ or ‘‘the conviction that he or she has the typical other sex, manifested as an intense desire to adopt the role of
feelings and reactions of the other sex’’—is fulfilled. With the other sex or to acquire the physical appearance of the
regard to the B criterion, only a persistent discomfort with other sex through hormonal or surgical manipulation. Within
one’s sex or a sense of inappropriateness in the gender role the GID criteria, a concept such as ‘‘cross-gender identifi-
associated with that sex is required. This implies that a man can cation’’ also assumes that there are only two gender identity
meet the two core criteria if he only believes he has the typical categories, male and female. As Bockting (2008) points out,
feelings of a woman and does not feel at ease with the male ‘‘Transsexuals were candidates for a change in sex…and the
gender role. The same holds for a woman who only frequently emphasis of the Real Life Test was on ‘passing’ in ‘the
passes as a man (e.g., in terms of first name, clothing, and/or opposite’ gender role’’ (p. 214). However, gender problems
haircut) and does not feel comfortable living as a conventional come in many forms and they may reflect gender identities
woman. Someone having a GID diagnosis based on these other than male or female.
subcriteria clearly differs from a person who identifies com- Bockting (2008) asked 1,229 U.S. transgendered persons
pletely with the other sex, can only relax when permanently to describe their transgender identity. Besides the more
living in the other gender role, has a strong aversion against the classical binary view on transgenderism, reflected in respon-
sex characteristics of his/her body, and wants to adjust his/her ses such as ‘‘female-to-male’’ and ‘‘male-to-female,’’ ‘‘for-
body as much as technically possible in the direction of the merly transsexual,’’ ‘‘woman with a correctible birth defect,’’
desired sex. and ‘‘displaced male,’’ a number of responses reflecting more
In adolescents and adults, the persistent discomfort with of a continuum or categories different from male/female were
one’s sex or sense of inappropriateness in the gender role also given. Examples of this more gender diverse view are
of that sex is, according to the DSM-IV-TR, manifested by ‘‘in-between and beyond,’’ ‘‘shemale,’’ ‘‘bigender/two-spirit,’’
symptoms such as a preoccupation with getting rid of one’s ‘‘third gender,’’ ‘‘genderless,’’ gender neutral,’’ ‘‘pan-/poly-/or
primary and secondary sex characteristics (e.g., request for omnigendered,’’ ‘‘gender fluid,’’ ‘‘intergendered,’’ ‘‘M2T
hormones, the surgery, or other procedures to physically alter dyke tomboy,’’ ‘‘butch queen,’’ ‘‘75% female but no plans on
sexual characteristics to simulate the other sex) or the belief surgery or hormones,’’ and ‘‘androgynies.’’ In contrast to the
that he or she was born the wrong sex. The current formula- traditional binary view, gender variance may be conceptualized,
tion thus indicates that the wish to completely alter one’s as gender variant people apparently already do, as a multidi-
body (e.g., a complete sex reassignment) is optional for hav- mensional or sometimes idiosyncratically conceptualized, mul-
ing a diagnosis. Again, this implies that individuals having ticategorical construct (e.g., Cole, Denny, Eyler, & Samons,
varying degrees (and perhaps types) of cross-gender iden- 2000).
tification and discomfort with their sex characteristics, which The gender issues of some, but not all, gender variant
constitutes a broad range of gender variant people, may all people will signify distress as a result of a ‘‘discrepancy be-
fulfill the DSM criteria for GID. Yet, in publications on GID, tween anatomic sex and gender identity’’ (Bornstein, 1994;
virtually no attention is paid to the severity of the condition. It Ekins & King, 2006; Lev, 2007; Røn, 2002), but it is unlikely
might be argued that other DSM diagnoses (e.g., mood dis- that all gender variant people fulfill current GID criteria. In
orders) also cover variations in severity. In the case of some those who do experience distress, this may vanish once they
mood disorders, however, this aspect is explicitly addressed. have accepted one of the previously mentioned definitions as
We believe that, in the case of a treatment as drastic as sex an adequate definition of themselves and are able to live
reassignment, which is a unique treatment in psychiatry, the accordingly. In others, some distress may remain, resulting in
diagnosis on which treatment decisions are based should be a life-long search for new adaptations. In again others, the
either as specific and unequivocal as possible or, alterna- behaviors may be an expression of persisting gender variant
tively, it should be made much more explicit than hitherto in identities, but not necessarily complete cross-gender identi-
the DSM-IV and DSM-IV-TR that the gender identity related ties (e.g., Diamond & Butterworth, 2008; Lee, 2001).
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The person’s awareness of one’s (more or less complete) The Potential Risk of Unnecessary Physically Invasive
atypical identity has also resulted in different treatment goals. Examinations to ‘‘Rule Out’’ Intersex Conditions If the C
For instance, a group of individuals reporting to have a ‘‘third,’’ Criterion Remains Part of the Diagnosis
‘‘other’’ or ‘‘nor male nor female’’ gender identity seek contact
with medical professionals to have surgical or chemical cas- The C criterion of the diagnosis, ‘‘The disturbance is not
tration only (Johnson, Brett, Roberts, & Wassersug, 2007; concurrent with a physical intersex condition,’’ was included
Wassersug, Zelenietz, & Squire, 2004). Indeed, clinicians because gender dysphoria in individuals with and without
in gender identity clinics are increasingly confronted with intersex conditions (now called disorders of sex development
treatment goals other than complete sex reassignment. Hage or DSD; Hughes, Houk, Ahmed, Lee, & LWPES/ESPE
and Karim (2000) reported that, even in the years that their Consensus Group, 2006) differ in a number of ways. Meyer-
gender identity clinic in Amsterdam did not offer partial Bahlburg (1994, in press) demonstrated differences between
treatment, only 138 of 352 female-to-male applicants for sex the groups in prevalence, age of onset or presentation, sex
reassignment surgery, who were referred for treatment over ratio, and associated or predictive factors. Because gender
20 years, underwent phalloplasty. Of the 1,049 male-to-fe- dysphoria does occur in individuals with DSD and gender
male applicants, 24% had hormone therapy but no genital identity was not considered to be entirely dependent on
surgery. A considerable number of ‘‘sex reassignment surgery biological factors, gender dysphoric individuals with DSD
applicants’’ were apparently not pursuing genital surgery at all. were classified as having a GIDNOS diagnosis.
Because sex reassignment surgery is covered by insurance in Some advocate deleting this criterion (e.g., eminism.org).
the Netherlands, it is unlikely that the choice of no surgery or They state that clinicians now sometimes perform physically
partial surgery was due to financial reasons. Although this lack invasive (and probably expensive) examinations with the
of interest in genital surgery may partly be explained by cau- only purpose to ‘‘rule out’’ DSD. Clinically, this makes no
tion because of the less than optimal surgical results, gender sense. In adolescents or adults, a simple examination will
identity related motives may also play a role. show whether there are symptoms of primary or secondary
When the policy of this clinic changed and individuals sex characteristics possibly indicative of DSD. In their ab-
requesting partial treatment were not a priori rejected for sence, ‘‘invasive’’ diagnostic procedures do not have to be
assessment and treatment, ‘‘atypical’’ treatment wishes were performed. Only in their presence, which is rare, ‘‘invasive
more often explicitly formulated at application. Some natal procedures’’ may be necessary, because they may have sig-
females, for instance, wish to have a metaidoioplasty, but nificant implications for the person’s understanding of their
keep their neoscrotum open, as they still want to use their gender issues as well as important implications for genital
vaginal opening for sexual contact. Natal males may want to surgery and sometimes for hormone treatment or cancer risk
have estrogens and breast enlargement surgery, but no vag- assessment.
inoplasty. Such treatment goals may reflect a gender identity
other than a complete cross-gender identity. In the years 2007 The Necessity of the D Criterion for a GID Diagnosis
and 2008, about 10% of the Amsterdam applicants for medi-
cal treatment desired partial medical treatment (certain hor- In the DSM-IV and DSM-IV-TR, the point A (cross-gender
mones and/or certain types of surgery only). Although the identification) and B criteria (discomfort with one’s assigned
first versions of the SOC of the WPATH only focused on sex) are necessary in order to be able to make the diagnosis.
‘‘complete’’ (that is, feminizing/masculinizing hormone treat- The question is whether the D criterion (impairment or dis-
ment and surgery) sex reassignment for transsexuals, the cur- tress) is equally necessary. Applicants for sex reassignment
rent version (Meyer et al., 2001) acknowledges the spectrum indeed often experience their gender dysphoria as unbearable
of gender variant developments and accompanying wishes and as having a tremendous negative impact on their lives.
for medical interventions other than ‘‘complete sex reassign- Even if they have satisfying social and family contacts and
ment.’’ Rather than determining if a person is a ‘‘true’’ trans- are successful at work, the burden of their gender dysphoria
sexual and thus eligible for a complete sex reassignment, may impede or even damage their functioning. A relationship
hormone therapy and surgery are seen as separate treatment between psychological or social impairment and GID is also
options in their own right. Yet, many professionals still do not suggested by reports on a relatively high prevalence of psy-
medically treat persons who do not completely fulfill GID chiatric problems among individuals with GID (e.g., Bodl-
criteria. und, Kullgren, Sundblom, & Höjerback, 1993; De Cuypere,
The heterogeneity of gender variant individuals suggests Janes, & Rubens, 1995; Hepp, Kraemer, Schnyder, Miller, &
that dimensionality in the diagnosis would be a much better Delsignore, 2005). This may have various causes. Social
reflection of the gender variance spectrum than the current stigma is one possible factor (e.g., Nuttbrock et al., 2009),
categorical one. difficulty of getting appropriate treatment, or rejection by
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family and friends (Factor & Rothblum, 2007; Ryan, Hueb- Unfortunately, if one does not consider their condition as
ner, Diaz, & Sanchez, 2009) are other ones, as well as the inherently distressful, a DSM-IV-TR GID diagnosis cannot
experienced incongruence between one’s gender identity presently be given to applicants for sex reassignment. This
and physical characteristics, which may be disconcerting in implies that well functioning applicants who report to be free
itself. of distress would, for this reason, not be eligible for sex
High percentages of psychiatric comorbidity, however, reassignment. Currently, clinicians solve the dilemma by
are not always found. In many studies, transsexuals were focusing on the ‘‘dysphoria’’ aspect of the diagnosis and, in
found to generally function well psychologically in the non- these cases, consider the distress as ‘‘inherent’’ to the con-
clinical range (e.g., Cole, O’Boyle, Emory, & Meyer, 1997; dition, because treatment exclusion of the well functioning
Gómez-Gil, Trilla, Salamero, Godás, & Valdés, 2009; Har- group would be highly undesirable. Dysphoria does have the
aldsen & Dahl, 2000; Mate-Kole, Freschi, & Robin, 1990; original meaning of ‘‘painfulness’’ or ‘‘distress.’’ If the new
Miach, Berah, Butcher, & Rouse, 2000; Seikowski, Gollek, diagnosis would focus more on the dysphoria aspect (e.g., in
Harth, & Reinhardt, 2008; Smith, van Goozen, & Cohen- the name) than does the current one, no separate distress
Kettenis, 2001; Smith et al., 2005). Indeed, clinically, one criterion would be necessary, because the distress would be
may see applicants who are employed, have relationships, defined as inherent to the diagnosis. The actual amount of
and function socially without any problems, yet very strongly experienced and reported distress may vary between indi-
desire sex reassignment. They state that they do suffer from viduals. It is currently unknown how often gender dysphoric
the incongruence between their anatomic sex and gender applicants for treatment are indeed free of distress. It is con-
identity, but that it does not interfere with their lives to the ceivable that, in some, reported levels at the time of applica-
point that they are not able to function satisfactorily. This tion are not high enough to qualify for a mental disorder,
implies that impairment is not necessarily associated with and there are arguments to delete the distress requirement
gender dysphoria, although older applicants may have expe- altogether (see also Meyer-Bahlburg, 2009). However, a dia-
rienced periods in their lives in which they did not function gnosis without a distress criterion or without the assump-
well. tion that distress is ‘‘inherent’’ to the diagnosis, may not be
Absence of impairment is most clearly illustrated by some considered suitable for the reimbursement of treatment. Also,
of the adolescents who want sex reassignment. In the Neth- many ‘‘distress-less’’ gender variant individuals do not attend
erlands, adolescents are eligible for pubertal delay with clinics. In epidemiological studies, it would be difficult to
GnRH analogues if they are fulfilling criteria for GID from make a distinction between those who would and would not
early childhood on, have reacted with an increase of the fulfill the diagnostic criteria, and there would be a risk of
gender dysphoria to the first pubertal changes, have no psy- pathologizing those who are satisfied with their lives and stay
chological problems that may interfere with the diagnostic away from clinical interventions. By defining gender dys-
work-up or with treatment, can be adequately supported phoria as distressful in itself, clinicians would no longer have
during treatment, and demonstrate knowledge and under- to make a separate estimation of the amount of distress in
standing of the treatment and its consequences (Cohen- deciding whether or not someone has the diagnosis and is
Kettenis, Delemarre-van de Waal, & Gooren, 2008). The eligible for treatment. Presently, it is unclear whether DSM-V
ones who had supportive parents, who knew already in child- will retain separate a distress/impairment criterion.
hood that they could have puberty delaying treatment soon
after the first physical signs of puberty and prior to cross-
sex hormone treatment, and who had accepting peers and The Fact that the Diagnosis Still Applies to Postoperative
teachers usually do not remember any impairment, distress or Transsexuals
suffering in childhood or early adolescence. At the time of
referral, all want to live in the other gender role (something In a postoperative and hormonally treated individual, the
they often already do before their referral to gender identity treatment has changed some sex characteristics and has fa-
clinics) and strongly desire hormone and surgical treatment, cilitated living in the desired gender role. However, the treat-
but, probably because of this lack of impairment or even ment has not changed the (natal) sex of that person. Because
current distress, adolescent applicants for sex reassignment the A criterion refers to nonconformity to one’s natal sex, it still
as a group function psychologically better than adult appli- applies to post-treatment individuals. After treatment, the
cants (de Vries, Kreukels, Steensma, Doreleijers, & Cohen- person will still ‘‘pass’’ frequently as ‘‘the other sex,’’ desire to
Kettenis, 2009). Their functioning is in sharp contrast to that live or be treated as ‘‘the other sex,’’ or feel that he or she has the
of adolescents living in less accepting environments, and who typical feelings and reactions of ‘‘the other sex.’’ The desire for
may be at high risk for self-harm and suicidal behavior (Di hormone treatment, or the belief that he or she was born the
Ceglie, Freedman, McPherson, & Richardson, 2002; Gross- wrong sex, which are both indicators of the B criterion, are not
man & D’Augelli, 2007). likely to change after treatment either. Without a change in
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Arch Sex Behav (2010) 39:499–513 505
formulation of the criteria or a specific statement in the text Considering the fact that the above criteria seem to have
addressing this issue, even post-surgical individuals will been clinically useful (primarily when making sex reas-
continue to fulfill the criteria for GID and thus can be diag- signment decisions) in the past, and that no other criteria have
nosed with a mental disorder for the rest of their lives. As been proposed thus far, there seems to be no need for entirely
having a mental disorder diagnosis may have adverse impli- new criteria to indicate gender dysphoric conditions. Criteria
cations for employment, insurance, etc., the diagnosis should which do not have a dysphoric component (e.g., ‘‘desire to
exclude treated individuals who are no longer gender dys- live as a member of the other gender’’) should be modified to
phoric. This could be done either by changing the formulation prevent unnecessary pathologizing of non-clinical gender
of the criteria or explicitly excluding this group from the di- variance (Winters, 2009).
agnosis in the text. Those who seek psychological treatment
postoperatively do not need a gender dysphoria-related diag-
nosis. Instead, other diagnoses, such as adjustment disorder or Dimensionality of the Diagnosis
depression, may be more appropriate. For postoperative hor-
mone treatment, other medical diagnoses, such as hypogonad- An important disadvantage of categorical diagnoses is loss
ism, may be used in a similar way. of information (Helzer, Kraemer, & Krueger, 2006). This is
one of the reasons that there is a growing interest in add-
ing dimensional components to DSM diagnoses, whenever
Core Criteria appropriate. For example, anxiety could be measured by using
an anxiety scale, but only those scoring above a certain cut-off
If one were to adjust the current criteria set, what criteria level would qualify for the diagnosis. As stated earlier, gender
would be good candidates? In the DSM-III, the core criteria variance or transgender phenomena are very heterogeneous.
of transsexualism were (A) a discomfort and inappropriate- Trying to force the whole variety of conditions into one dis-
ness about one’s anatomic sex and (B) the wish to be rid of crete category has already created disadvantageous clinical
one’s own genitals and live as a member of the other sex decisions. In the DSM-IV-TR, one may fulfill the GID diag-
(Appendix 1). In the DSM-III-R, they were (A) a sense of nosis if one’s GID is manifested by ‘‘partial’’ treatment goals
inappropriateness about one’s assigned sex and (B) a per- (e.g., some form of surgery only). However, such partial
sistent preoccupation with getting rid of one’s primary and treatment is often refused, because GID is still considered to be
secondary sex characteristics and acquiring the sex charac- identical to the former transsexualism diagnosis and, for this
teristics of the other sex. In the DSM-IV and DSM-IV-TR condition, (complete) sex reassignment is seen as the treatment
versions, they were (A) a cross-gender identification and (B) of choice.
a discomfort with his or her sex. In the past and current DSM Although not all gender variance requires clinical atten-
versions, three aspects were considered relevant: (1) gender tion, many conditions, ranging from mild to extreme, do. The
identification, (2) gender role, and (3) physical aspects. Inter- clearest example of extreme gender dysphoria consists of the
estingly, in earlier DSM versions, a cross-gender identifica- category that is still often labeled as transsexualism. For these
tion was not a separate criterion, but apparently inferred from gender dysphoric conditions, a dimensional diagnosis could
the desire to live as a member of the other sex (combined with be made in various ways. One possibility would be to just add
the discomfort about one’s own sex). Thus, the core criteria up some or all of the already existing indicators. Some would
for transsexualism (DSM-III and DSM-III-R) or GID (DSM- need to be adjusted, because of the earlier mentioned criti-
IV and DSM-IV-TR) have always consisted of combinations cisms. For instance, natal sex and the present somatic/genital
of the following elements (see also Table 1): situation are not distinguished in the current criteria, which
led to the problem that even postoperative well-adjusted
1. Cross-gender identification (1)
individuals can still be diagnosed with the current GID diag-
2. Desire to live as a member of the other sex (2)
nosis.
3. Sense of inappropriateness in the gender role belonging
If the adjusted criteria would be used again, the new
to one’s natal sex (2)
diagnosis should consist of the following indicators1:
4. Discomfort about one’s assigned sex (2)
5. Desire to have sex characteristics of the other sex (3) 1. Strong sense of discomfort with the gender role associ-
6. Discomfort about one’s anatomic sex (3) ated with one’s assigned gender
7. Wish to get rid of one’s natal sex characteristics (3)
The GIDNOS diagnosis in the DSM-III-R and DSM-IV-
TR, and the diagnosis GIDAANT in the DSM-III-R, were
meant to be used for all other types of clinically relevant 1
These criteria do not include the subsequent workgroup discussions.
gender variance. They likely do not reflect the final criteria.
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Table 1 Core criteria of transsexualism or GID in DSM-III to DSM-IV-TR

DSM-III DSM-III-R DSM-IV-TR (GID)
(transsexualism) (transsexualism)
Cross-gender identification A-criterion

Desire to live as a member of the opposite sex B-criterion (as symptom of A-criterion)
Sense of inappropriateness in gender role belonging to B-criterion
one’s sex
Discomfort about one’s assigned sex A-criterion
Desire to have sex characteristics of the other sex B-criterion (as an example of a symptom
of B-criterion)
Discomfort about one’s anatomic sex A-criterion B-criterion
Wish to be rid of one’s own sex characteristics B-criterion B-criterion (as symptom of B-criterion)
2. Strong discomfort with one’s primary and/or secondary criteria, ‘‘completeness’’ or ‘‘extremeness’’ would be appro-
sex characteristics, because they do not match one’s gen- priate; for others, ‘‘intensity,’’ ‘‘duration,’’ or ‘‘persistence.’’
der identity2 However, it would be very difficult to obtain clinician agree-
3. Strong desire to be rid of one’s primary and/or secondary ment on such aspects, and probably unnecessarily complicate
sex characteristics, because they do not match one’s gen- diagnosis making. The accompanying text should state ex-
der identity plicitly that the diagnosis no longer applies to persons who had
4. Strong desire for primary and/or sex characteristics that their hormonal and/or surgical treatment. For postoperative
match one’s gender identity individuals with regret, adjusted formulations are necessary. If
5. Distress caused by a strong desire to live in the gender the criteria would be used for individuals with DSD (but see
role of the other gender and/or to be perceived by others Meyer-Bahlburg, 2009), the formulation of the criteria would
as a member of the other gender (or some alternative gen- also have to be adapted for this group.
der different from one’s assigned gender) In a consensus meeting on the DSM-V of the WPATH,
6. Distress caused by a strong identification with the other held in Oslo, June 2009, it was stated that separate criteria for
gender (or some alternative gender different from one’s adolescents should be considered. As in many other diag-
assigned gender) noses, the clinical management may differ considerably be-
tween the two age groups. However, specific adolescent is-
The difference between a diagnosis, such as this one, and
sues (e.g., pubertal delay as a diagnostic aid) are more appro-
the earlier DSM diagnoses is that, in previous versions, one
priately addressed in the supporting text than in a separate set
needed to fulfill all primary criteria to have the diagnosis. In
of diagnostic criteria.
this conceptualization, in principle one could have a diag-
nosis if only one of the criteria is fulfilled. The required
number of indicators to differentiate gender dysphoric from
The Concept of Gender Dysphoria
non-gender dysphoric individuals needs, of course, to be
investigated in further studies.
If a gender variance-related diagnosis would stay in the DSM,
Because it is possible that one only needs to fulfill one
a more appropriate term or name should be selected. This term
criterion in order to be gender dysphoric, the prevalence of
needs to fulfill a number of requirements. The term should (1)
this condition, which would be heterogeneous in type and
clearly express the heart of the problem, the discontent with
intensity, would probably be much higher than the current
one’s physical sex characteristics and/or assigned gender, and
estimates of transsexualism or GID (Zucker & Lawrence,
not be applicable to gender variant individuals without this
2009). As in the case of homosexuality, a high prevalence of
discontent; (2) be dimensional; it should be possible to have
gender dysphoria in the general population would raise more
more or less complete forms of the condition; (3) allow fluc-
questions on whether the condition should be considered a
tuations, i.e., increase as well as decrease over time, and, fi-
mental disorder (Drescher, 2009).
nally, (4) it should be acceptable and non-stigmatizing to those
To further dimensionalize the diagnosis, one may even
who fulfill criteria 1–6 of the revised diagnostic criteria.
consider assigning weights to each of the elements. For some
Considering these requirements, ‘‘gender dysphoria’’ seems
an appropriate term. This was also concluded in the earlier
mentioned WPATH consensus meeting on the DSM-V. It is
2
For young adolescents, this criterion also refers to anticipated sex clear what someone with gender dysphoria suffers from, one
characteristics (Winters, 2009). can be more or less gender dysphoric, one can suffer from it,
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but, with or without treatment, some or all criteria may no in the case of MTFs, diminished sometimes to zero by estro-
longer be applicable. It further seems that the term is relatively gen’’ (p. 49). This picture was certainly related to the ramifi-
well-accepted in the transgender community, although some cations of the McCarthy era and its anti-sexual bias. Data from
may prefer even more neutral terms, such as ‘‘gender discor- Sweden from the 1970s about regrets after sex reassignment
dance,’’ ‘‘gender dissonance,’’ ‘‘gender discomfort’’ or ‘‘gen- surgery also characterized transsexuals as having a weak
der incongruence.’’ sexual libido (Wålinder, Lundström, & Thuwe, 1978). This
thinking about the sexuality of transsexuals has also influenced
treatment decisions. For instance, the first treatment programs
Gender Dysphoria and Treatment Decisions for transsexuals in Australia strictly excluded MTF transsex-
uals if they had a history of active engagement in ‘‘homosex-
As with other diagnoses, treatment and diagnosis are not ual’’ encounters (Ball, 1981; Ross & Need, 1989). Lundström
related in a simple way. What is considered suitable will (1981) reported long marriages and high sexual partner mobi-
depend on the specific combination of symptoms, as well as lity to be predictors of poor outcome. Wålinder et al. (1978)
other, non diagnosis-related aspects. For instance, someone warned to be cautious when applicants for sex reassignment
who is distressed because of a strong desire to live in the surgery show a strong sexual interest or have heterosexual
gender role of the other gender might qualify for some form of experience, because this may indicate ‘‘a lower intensity of
psychotherapy. However, someone fulfilling this criterion transsexual symptomatology and consequently ambivalence
and also having a strong desire to be rid of his or her primary towards sex reassignment’’ (p. 19). On the other hand, Ben-
and/or secondary sex characteristics, who applies for breast jamin (1966) identified various forms of sexual activity before
removal would probably not be helped by psychotherapy sex reassignment surgery as positive predictors for outcome,
only. Whether a cut-off point for the previous diagnosis of and the results he reported confirmed this. It is likely that,
transsexualism would be desirable and what this cut-off point depending on the criteria of access to treatment in a specific
should be remains to be investigated. treatment facility, applicants adjust their biographical data
with regard to sexuality. This makes the quality of the infor-
mation, especially when given during clinical assessment,
Specifiers questionable.
Another problem concerning the usefulness of sexuality-
DSM-IV (American Psychiatric Association, 1994) and DSM- related GID specifiers regards the stability of sexual orienta-
IV-TR require, for sexually mature individuals with a diagnosis tion. In the discussion on homosexuality (of individuals
of GID, to specify to whom they feel sexually attracted. They without GID), the stability or instability of sexual orientation
offer four alternatives, i.e., sexually attracted to males, to fe- has been a matter of debate. Recently, prospective studies in
males, to both, and to neither. This subdivision is largely based non-transsexual samples of women suggest that there is con-
on the work of Blanchard and colleagues (e.g., Blanchard, 1989; siderable fluidity in sexual orientation, especially for women
Blanchard, Clemmensen, & Steiner, 1987). These specifiers (Diamond, 2000; Diamond & Butterworth, 2008). In the
were recently challenged by Veale, Clarke, and Lomax (2008), 1990s, the question arose if the preferences for the gender of
but their critique was rebuked by Lawrence and Bailey (2008) sex partners would also change in the course of hormonal and
and by Lawrence (in press). surgical treatment (e.g., Daskalos, 1998; Lawrence, 1999, 2005).
Looking at the history of transsexualism, the development As Lawrence (1999) points out, it is extremely difficult to assess
of gender identity clinics with the availability of sex reas- such changes in individuals with a GID diagnosis, as they pre-
signment surgery, and the diversity of social and cultural operatively might give information only to be admitted to hor-
contexts in which such services were and are offered, it is monal and surgical treatment. However, there is no doubt that
obvious that social and cultural biases have greatly influ- changes as to the preferred gender of sex partner do occur (De
enced diagnostic criteria and the access to hormonal and Cuypere et al., 2005; Lawrence, 2005; Schroder & Carroll, 1999;
surgical treatment. some 30 in a sample of more than 1,200 GID patients seen by
When in the mid-1960s, the first gender identity clinic was F.P.).
established at the Johns Hopkins University Clinic in Balti- Over the years, various sexuality related subcategories have
more, transsexuals were described as being rather asexual been proposed (e.g., Blanchard, 1989; Blanchard et al., 1987;
(e.g., Money & Ehrhardt, 1970; Pauly, 1965). In an early paper, Buhrich & McConaghy, 1978; Freund, Steiner, & Chan, 1982;
transsexualism was characterized as ‘‘an escape from…sexual Money & Gaskin, 1970–1971; Sørenson, 1981; for a review,
impulses’’ (Worden & Marsh, 1955, in Meyerowitz, 2002). see Lawrence, in press). In clinical writings, there seems to be
Benjamin (1966) asserted that ‘‘Many transsexuals have no agreement that transsexual subtypes do exist, although there is
overt sex life at all, their sex drive being low to begin with and, no agreement on the number and kind of relevant subtypes.
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Although sexual orientation subtyping may be of interest to ably prospective, research, as retrospective data of adults
researchers in the field, no clinical decisions are currently based regarding the date of onset of their feeling of being different are
on this classification. Also, in the transgender community, not reliable. Such research should perhaps even differentiate
there is strong resistance against subtyping on the basis of between onset in various phases (e.g., very early childhood
sexual orientation and activity and even against having to [before the age of about 3 years], childhood until puberty,
give this information for scientific purposes only. This was adolescence, and adulthood) as it is conceivable that more than
also concluded by clinicians attending the WPATH consen- the two currently described routes exist. It should also be
sus meeting (Oslo, June 2009). The term autogynephilia, precise as to what exactly is considered to be ‘‘early onset’’: the
which is used for one subtype, is considered highly offensive presence of certain cross gender behaviors and/or preferences,
by some (e.g., Winters, 2005, 2008). The finding that ‘‘homo- anatomic dysphoria or a full GID diagnosis. Future research
sexual’’ and ‘‘nonhomosexual’’ subgroups differed in psy- will have to show also whether making a distinction between
chological functioning (Smith et al., 2005) could not be repli- the subgroups is clinically useful.
cated in a yet unpublished recent study at the same gender Although there are no convincing data on the clinical
identity clinic. The first study was conducted in the early utility of both subtypes, for research purposes it does seem to
1990s, when relatively few people had Internet access and be important to make a distinction between subtypes. For
applicants were not well informed about the fact that this instance, in etiological research, which is still in a not very
topic was hotly debated (Smith et al., 2005). It is therefore advanced stage, one may need to take the distinction into
likely that, more than 10 years later, the increased awareness account. It would also be worthwhile to investigate the
regarding the sexual orientation issue has led to less reliable relationship between onset age and sexual orientation more
reports of sex reassignment applicants on their sexual ori- extensively. If they are highly correlated and onset age has
entation. Considering the disadvantages and few, primarily proven its clinical utility, onset age rather than sexual ori-
research related, advantages of this subdivision, one should entation could be used.
reconsider sexual orientation as a specifier. Lawrence (in press) compared sexual orientation versus
In the DSM-IV-TR, it is noted that the developmental routes age of onset as specifiers for the diagnosis of GID, using
are different for transsexual individuals with a very early cross- seven criteria: (1) Is the specifier unambiguous? (2) Can it be
gender identification (childhood) versus those who report easily ascertained? (3) Can it be ascertained reliably? (4)
cross-gender identification starting after puberty. In a sub- Does it facilitate concise, comprehensive clinical descrip-
sequent study, such developmental routes were confirmed by tion? (5) Does it provide prognostic value for treatment-
Smith et al. (2005). In children around the age of 3 years, one related outcomes? (6) Does it provide predictive value for
may observe cross-gender behaviors without this being a clear comorbid psychopathology? (7) Does it facilitate research
cut predictor for later gender dysphoria or the wish for sex and offer heuristic value? While Lawrence concludes that
reassignment in adulthood. The children act differently than only the second of these questions is confirmed for the age of
their same-sex peers, but are not yet able to mentalize and to onset specifier, Lawrence found confirmation of all seven
verbalize their feeling of ‘‘otherness.’’ It seems that only when questions for the sexual orientation specifier. It is no surprise
this feeling of being different is verbalized by the child and that Lawrence concluded that the sexual orientation specifier
incorporated in the child’s sense of self that this increases the is superior to the age of onset specifier, and should remain in
likelihood of later transgenderism. But even then, factors the DSM. However, Lawrence also indicates that onset age
influencing the ongoing development in prepuberty and pub- has hardly been studied, because, historically, there was more
erty may still play a decisive role as to the persistence of such scientific interest in sexual orientation than in onset age.
feelings of ‘‘otherness.’’ While the first large prospective study Considering the need for a better understanding of the phe-
of young children (feminine boys who fulfilled some or all of nomenon of gender dysphoria, one might therefore draw just
the GID criteria) showed that in nearly all the gender dysphoria the opposite conclusion: that it is the importance of onset age
disappeared (Green, 1974, 1985, 1987), more recent data for the long-term development of gender dysphoric individ-
demonstrate that about 10–25% will continue to be gender uals we need to know much more about. Lawrence also does
dysphoric (Drummond, Bradley, Peterson-Badali, & Zucker, not address the possibility that sexual orientation has become
2008; Wallien & Cohen-Kettenis, 2008; Zucker & Bradley, so controversial that, in a clinical setting, the information
1995). With regard to sexuality, it was found that transsexuals given by applicants for medical interventions may have be-
attracted to partners of their natal sex more often belonged to come invalid. For these reasons, it is likely that a specifier
the early onset group than the ones attracted to partners of the focusing on onset age, provided that it is clearly defined and
other sex. It is likely that there is an overlap between the well measured, will contribute even more to our under-
groups, but this would have to be confirmed by more, prefer- standing of gender dysphoria than sexual orientation.
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Arch Sex Behav (2010) 39:499–513 509
Recommendations this article. The article also benefited from the discussions at the sym-
posium of the American Psychiatric Association ‘‘In or Out?: A Dis-
cussion about Gender Identity Diagnoses and the DSM,’’ San Francisco,
Considering the criticisms regarding the A and B criteria, there May 2009; and WPATH’s symposium ‘‘WPATH’s Consensus State-
are two possibilities. ment on Gender Dysphoria and the DSM-V,’’ Oslo, Norway, June 2009.
Reprinted with permission from the Diagnostic and Statistical Manual
1. One possibility is to leave the criteria as they are, but to of Mental Disorders V Workgroup Reports (Copyright 2009), American
make them more stringent. This means returning to the Psychiatric Association.
dichotomy of the DSM-III and III-R, where only the former
‘‘transsexuals’’ had the diagnosis, and different or less
extreme types of gender dysphoria were all included in Appendix 1: Diagnostic Criteria of Gender Identity
NOS-like diagnoses or had no diagnosis at all. Although Disorders in the DSM (Adolescent and Adult Criteria)
most of the criteria and indicators would remain the same,
the ambiguity would have to be taken out of the formu- DSM-III
lations. Also, other adjustments (e.g., name change, exclu-
sion of the postoperative group, more focus on the dys- Transsexualism (302.5x)
phoria) would be needed. For less experienced clinicians A. Sense of discomfort and inappropriateness about one’s
who have yet to make sex reassignment eligibility deci- anatomic sex.
sions, it would be easier to work with this type of binary B. Wish to be rid of one’s own genitals and to live as a
classification than with the DSM-IV-TR type, where a GID member of the other sex.
diagnosis includes extreme as well as less extreme forms of C. The disturbance has been continuous (not limited to
gender dysphoria, and a GIDNOS diagnosis comprising yet periods of stress) for at least 2 years.
other forms of gender dysphoria. However, such a dicho- D. Absence of physical intersex or genetic abnormality.
tomy would disregard the wide variety of gender identity E. Not due to another mental disorder, such as Schizophrenia.
related phenomena clinicians encounter. It would also still
be of little help for treatment decisions and research regard- Subclassification by predominant prior sexual history:
ing the heterogeneous conditions included in the other, 1 = asexual
NOS diagnosis. Finally, it would maintain the use of the 2 = homosexual (same anatomic sex)
diagnosis in the obsolete search for the ‘‘true transsexual’’ 3 = heterosexual (other anatomic sex)
or ‘‘ideal surgical candidate.’’ 4 = unspecified
2. Another possibility would be to accommodate the in- Atypical Gender Identity Disorder (302.85)
creasing awareness of, and empirical support for, the This is a residual category for coding disorders in gender
variety of gender dysphoric conditions. This could be identity that are not classifiable as a specific Gender Identity
done by means of a more dimensional approach using, Disorder.
somewhat adjusted indicators that have been part of the
earlier DSM diagnoses. This approach allows for differ- DSM-III-R
ent degrees of gender dysphoria, and makes more explicit
that a diagnosis not necessarily implicates eligibility for Transsexualism (302.50)
sex reassignment. By giving the diagnosis the name of A. Persistent discomfort and sense of inappropriateness
gender dysphoria, distress would be an aspect of the di- about one’s assigned sex.
agnosis, making an extra distress/impairment criterion B. Persistent preoccupation for at least 2 years with getting
redundant. rid of one’s primary and secondary sex characteristics
Because of the strong resistance against sexuality related and acquiring the sex characteristics of the other sex.
specifiers, which may result in a still increasing unreliability of C. The person has reached puberty.
collected data, and the relative difficulty assessing sexual ori- Specify history of sexual orientation: asexual, homosex-
entation in individuals pursuing hormonal and surgical inter- ual, heterosexual, or unspecified.
ventions to change their sex characteristics, closer investigation Gender Identity Disorder of Adolescence or Adulthood,
of onset age as a potential specifier is warranted. Nontranssexual Type (GIDAANT) (302.85)
Acknowledgments The authors are members of the DSM-V Work- A. Persistent or recurrent discomfort and sense of inappro-
group on Sexual and Gender Identity Disorders (Chair, Kenneth J. priateness about one’s assigned sex.
Zucker, Ph.D.). We thank the other members of the Gender Identity
B. Persistent or recurrent cross-dressing in the role of the other
Disorders Subworkgroup (Jack Drescher and Heino F. L. Meyer-
Bahlburg) Kenneth J. Zucker, and two Work Group Advisors (Esther sex, either in fantasy or actuality, but not for the purpose of
Gómez-Gil and Stephen B. Levine) for their valuable contributions to sexual excitement (as in Transvestic Fetishism).
123
510 Arch Sex Behav (2010) 39:499–513
C. No persistent preoccupation (for at least 2 years) with Specify if (for sexually mature individuals):
getting rid of one’s primary and secondary sex charac- Sexually Attracted to Males
teristics and acquiring the sex characteristics of the other Sexually Attracted to Females
sex (as in Transsexualism). Sexually Attracted to Both
D. The person has reached puberty. Sexually Attracted to Neither
Specify history of sexual orientation: asexual, homosex-
ual, heterosexual, or unspecified.
Gender Identity Disorder Not Otherwise Specified
302.85 Gender Identity Disorder Not Otherwise (302.6)
Specified
This category is included for coding disorders in gender
Disorders in gender identity that are not classifiable as a identity that are not classifiable as a specific Gender Identity
specific Gender Identity Disorder. Disorder. Examples include
Examples: 1. Intersex conditions (e.g., partial androgen insensitivity
1. Children with persistent cross-dressing without the other syndrome or congenital adrenal hyperplasia) and accom-
criteria for Gender Identity Disorder of Childhood panying gender dysphoria
2. Adults with transient, stress-related cross-dressing behav- 2. Transient, stress-related cross-dressing behavior
ior 3. Persistent preoccupation with castration or penectomy
3. Adults with the clinical features of Transsexualism of without a desire to acquire the sex characteristics of the
less than 2 years’ duration other sex
4. People who have a persistent preoccupation with cas-
tration or penectomy without a desire to acquire the sex
characteristics of the other sex
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DOI 10.1007/s10508-009-9594-3
ORIGINAL PAPER
Sexual Orientation versus Age of Onset as Bases for Typologies

(Subtypes) for Gender Identity Disorder in Adolescents and Adults
Anne A. Lawrence
Received: 9 June 2009 / Revised: 21 December 2009 / Accepted: 22 December 2009 / Published online: 6 February 2010
Abstract The most widely used and influential typologies for Introduction
transsexualism and gender identity disorder (GID) in adolescents
and adults employ either sexual orientation or age of onset of Persons who experience persistent discomfort with their bio-
GID-related symptoms as bases for categorization. This review logic sex or with the gender role of that sex (gender dysphoria;
compares these two typological approaches, with the goal of American Psychiatric Association [APA], 2000) and who
determining which one should be employed for the diagnosis of display a strong and persistent cross-gender identification can
GID in Adolescents or Adults (or its successor diagnosis) in the be diagnosed with transsexualism (APA, 1980, 1987; World
forthcoming revision of the Diagnostic and Statistical Manual of Health Organization [WHO], 1992) or gender identity disor-
Mental Disorders (DSM). Typologies based on sexual orienta- der (GID; APA, 1994, 2000). Transsexualism has long been
tion and age of onset of GID-related symptoms are roughly com- recognized to be a ‘‘heterogeneous disorder’’ (APA, 1980, p.
parable in ease and reliability of subtype assignment. Typol- 261), and several different classification systems or typologies
ogies based on sexual orientation, however, employ subtypes that for transsexualism and GID have been proposed. Most of these
are less ambiguous and bettersuited to objective confirmation and typologies have addressed only male-to-female (MtF) trans-
that offer more concise, comprehensive clinical description. sexualism, because, until recently, only one type of female-to-
Typologies based on sexual orientation are also superior in their male (FtM) transsexualism was believed to exist. The most influ-
ability to predict treatment-related outcomes and comorbid psy- ential and widely used transsexual typologies have emphasized
chopathology and to facilitate research. Commonly expressed either sexual orientation or age of onset of GID-related symptoms
objections to typologies based on sexual orientation are unper- (e.g., gender dysphoria, unremitting gender dysphoria, cross-
suasive when examined closely. The DSM should continue to gender identification, or overt cross-gender behavior) as the prin-
employ subtypes based on sexual orientation for the diagnosis of cipal criterion for classification. Classification systems based on
GID in Adolescents or Adults or its successor diagnosis. sexual orientation have served as typologies or specifiers1 for the
Keywords DSM-V Gender identity disorder 1

The DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000) distin-
Transsexualism Sexual orientation Age of onset guish between subtypes and specifiers for diagnoses:
Typology
Subtypes define mutually exclusive and jointly exhaustive phe-
nomenological subgroupings within a diagnosis and are indicated
by the instruction ‘‘specify type’’ in the criteria set….In contrast,
specifiers are not intended to be mutually exclusive or jointly
exhaustive and are indicated by the instruction ‘‘specify’’ or
‘‘specify if’’ in the criteria set. (APA, 2000, p. 1)
A. A. Lawrence
Department of Psychology, University of Lethbridge, In the DSM-IV and DSM-IV-TR, criteria sets for the diagnosis of GID in
Lethbridge, AB, Canada Adolescents or Adults include instructions to specify sexual orientation,
i.e., sexually attraction to males, females, both, or neither (e.g., APA,
A. A. Lawrence (&) 2000, p. 582). These four categories, however, are mutually exclusive
6801 28th Avenue NE, Seattle, WA 98115, USA and jointly exhaustive; consequently, they should properly be consid-
e-mail: [email protected] ered subtypes, not specifiers. In the DSM-III-R (APA, 1987), the criteria
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Arch Sex Behav (2010) 39:514–545 515
diagnoses of transsexualism and GID in the Diagnostic and Transsexual typologies that emphasize neither sexual ori-
Statistical Manual of Mental Disorders (DSM; APA, 1980, 1987, entation nor age of onset of GID-related symptoms also exist
1994, 2000), ever since these diagnoses entered the DSM in (e.g., Buhrich & McConaghy, 1978; Freund, Steiner, & Chan,
1980. Transsexual typologies based on the age of onset of 1982; Sørensen & Hertoft, 1980, 1982) but are primarily of
GID-related symptoms have also been widely used, however, historical interest. I will address them only to the extent that they
especially in past decades and in some northern European are relevant to a comparison of the two most widely employed
countries (e.g., the Netherlands, Norway, Poland, and Swe- typological approaches.
den; see Cohen-Kettenis, van Goozen, Doorn, & Gooren,
1998; Doorn, Poortinga, & Verschoor, 1994; Haraldsen,
Opjordsmoen, Egeland, & Finset, 2003; Herman-Jeglińska, Early History of Sexual Orientation and Age of Onset
Grabowska, & Dulko, 2002; Johansson, Sundbom, Höjerback, as Descriptive Variables in Transsexualism
& Bodlund, 2009; Landén, Wålinder, Hambert, & Lundström,
1998). The International Classification of Diseases (WHO, Beginning with the earliest clinical descriptions of transsexu-
1992) does not employ any subtypes or specifiers for the diag- alism, sexual orientation has been considered an important
nosis of transsexualism. descriptive variable. Early investigators paid less attention to
As this article goes to press, the DSM is undergoing revision, a age of onset of GID-related symptoms as a descriptive variable,
process that is expected to produce a new edition, the DSM-V, in because onset was usually assumed to be very early in nearly all
2012 (APA, 2008). Accordingly, it is appropriate to reexamine cases. Only in the late 1960s and early 1970s, however, did cli-
the two principal bases for framing typologies for transsexual- nicians and researchers begin to use sexual orientation and age
ism—sexual orientation and age of onset of GID-related symp- of onset as criteria for framing formal transsexual typologies.
toms—and consider which one should be employed as the basis The emergence of these typologies partly reflected attempts to
for a typology for GID or its successor diagnosis in the DSM-V. In develop bases for selecting appropriate candidates for sex reas-
this article, I will review the history of these two typological signment surgery (SRS), which was becoming more readily
approaches and summarize the evidence concerning the value of available. Nearly all investigators have referenced the sexual
each for use with the diagnosis of GID. Specifically, I will con- orientation of transsexuals to birth sex; this convention should be
sider the extent to which typologies based on sexual orientation assumed, unless an exception is specifically noted.
versus age of onset of GID-related symptoms: (1) employ cate- Hirschfeld (1948, 1991) was arguably the first author to
gories (subtypes) that are unambiguous, easily ascertained, and devote significant study to the phenomenon now recognized as
reliable; (2) facilitate concise, comprehensive clinical descrip- transsexualism. Hirschfeld did not distinguish between the
tion; (3) offer prognostic value for treatment-related outcomes; conditions that are now called transsexualism and transvestic
(4) offer predictive value for comorbid psychopathology; and (5) fetishism; he referred to persons with either condition simply as
facilitate research and offer heuristic value. These criteria reflect ‘‘transvestites.’’In his earliest writings on the subject, Hirschfeld
the DSM’s emphasis on‘‘clinical utility, reliability, [and] descrip- (1991) expressed the belief that the sexual orientations of
tive validity’’(APA, 2000, p. xxvi) and its intention to‘‘facilitate the transvestic persons he studied—nearly all of whom were
research’’ (APA, 2000, p. xxiii). I will conclude by addressing males—were directed‘‘in almost all cases… toward persons of
some additional theoretical and practical issues related to the two the opposite [biological] sex’’(p. 130); the rare exceptions were
principal typological approaches, including several issues raised bisexual in orientation. Later, Hirschfeld (1948) recognized
by Cohen-Kettenis and Pfäfflin (2009). a wider range of sexual orientations among transvestic persons:
‘‘About 35 per cent of transvestites are heterosexual and an
Footnote 1 continued equal percentage homosexual, while about 15 per cent are bisex-
set for the diagnosis of Transsexualism includes an instruction to specify ual. The remaining 15 per cent are mostly automonosexual,
sexual orientation, i.e., asexual, homosexual, heterosexual, or unspec- but also include a small proportion of asexuals’’ (p. 167). The
ified (p. 76), but the accompanying text refers to these categories as
persons Hirschfeld called automonosexual, whose sexuality
‘‘types’’ (p. 75). These four categories, too, are mutually exclusive and
jointly exhaustive; according to the definitions of the DSM-IV and was primarily directed toward themselves rather than toward
DSM-IV-TR, they would also be considered subtypes. In the DSM-III other people, would now be called analloerotic, ‘‘not sexually
(APA, 1980), the criteria set for the diagnosis of Transsexualism includes attracted toward other people’’ (Blanchard, 1989a). Most sub-
subtype designations, based on prior sexual history, i.e., asexual, homo-
sequent transsexual typologies based on sexual orientation have
sexual, heterosexual, or unspecified (p. 262). These categories are also
mutually exclusive and jointly exhaustive, so their designation as subtypes drawn from the five categories that Hirschfeld (1948) set forth.
is consistent with the definitions of the DSM-IV and DSM-IV-TR. Note But, although Hirschfeld evidently believed that sexual orien-
that, in classification systems based on age of onset of GID-related symp- tation was a relevant variable in describing transsexualism, his
toms, the binary categories that are typically employed (e.g., early- vs. late-
observations seem to have been simply descriptive, not the
onset, or primary vs. secondary) are also mutually exclusive and jointly
exhaustive. According to the definitions of the DSM-IV and DSM-IV-TR, proposal of a formal typology. Hirschfeld (1991) had little to say
they would also be considered subtypes. about the age of onset of cross-gender wishes in the transvestic
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516 Arch Sex Behav (2010) 39:514–545
persons he studied, noting that‘‘in most of the cases we can trace only rarely did transvestism first manifest during the late teenage
the urge back into their early childhood’’(p. 125). years. Lukianowicz suggested, however, that a late onset of
Hamburger (1953), one of Christine Jorgensen’s physicians, gender dysphoria was characteristic of many cases of interme-
reported data from 465 persons who wrote to him requesting sex diate-intensity transsexualism, which ‘‘probably consists of
reassignment. He divided his male informants into‘‘transvestic’’ cases of very slowly developing transsexualism, presenting for
men, who emphasized their desire to cross-dress, and ‘‘other’’ years a typical picture of a ‘mere’ transvestism, and turning
men, who did not. This division, however, appeared to be purely eventually into transsexualism’’(p. 51).
descriptive and did not represent a proposed typology. Ham- Wålinder (1967) described 30 MtF and 13 FtM transsexual
burger reported the sexual orientations of his informants relative patients he had interviewed but did not propose a formal trans-
to anatomic sex, using three categories: heterosexual, homosexual typology. Twenty-eight of the 30 MtF patients and all of
sexual, and bisexual/autosexual (i.e., analloerotic) or asexual. the FtM patients described themselves as sexually aroused
Among the informants who included information about their ‘‘mentally’’by same-sex persons; the remaining 2 MtF patients
sexual orientations, about 40% of the transvestic males and were mentally aroused by opposite-sex persons. The reported
87% of the nontransvestic males were homosexually oriented, age of onset of the wish to be the other sex was 0–5 years in all of
whereas all of the females were homosexually oriented. the FtM patients and in two-thirds of the MtF patients; in the
Hamburger said little about the age of onset of gender dysphoria remaining MtF patients, reported age of onset of cross-gender
or cross-gender identity in his informants, noting only that‘‘the wishes was about equally divided between 5–10 years, 10–15
desire for change of sex appears before puberty’’(p. 375). years, and 15–25 years.
Randell (1959) described 20 male and 10 female transsexual Meyer (1974) described several clinical variants among
patients, along with 17 male and 3 female transvestite patients. He persons applying for sex reassignment. His descriptions can be
reported the sexual orientation of the male patients using the 0–6 conveniently considered here, even though they involved quasi-
Kinsey scale (Kinsey, Pomeroy, & Martin, 1948), observing that typological categories and arguably were not truly ‘‘early.’’ On
most of the MtF transsexuals fell into the heterosexual-bisexual the other hand, Meyer did not claim to present a comprehensive
range (Kinsey 1–3; none were Kinsey 0) but that one quarter were typology of severely gender dysphoric persons. Meyer’s cate-
exclusively homosexual (Kinsey 6). Randell found, however, that gories were largely based on sexual orientation, in that they
‘‘with one notable exception, the female patients were homo- reflected patients’‘‘sexual object choice, erotic preference, fan-
sexually orientated’’ (p. 1450). Here again, the author’s obser- tasies, and interpersonal social maneuvers’’ (p. 529). The cate-
vations concerning sexual orientation appeared to be simply gories included (a) stigmatized homosexuals and masochists,
descriptive, not indicative of a proposed transsexual typology. who were actively and exclusively homosexual, or nearly so; (b)
Randell described the age of onset of the patients’ cross-gender aging transvestites and younger transvestites, who were pri-
feelings only briefly, observing that, in transsexual and trans- marily heterosexual and who displayed prominent cross-gender
vestite patients of both sexes, ‘‘the onset of the transvestite fetishism; (c) polymorphous perverse applicants, who were not
impulse was early, usually before the age of 10 years’’(p. 1450). exclusively homosexual and whose sexual behaviors were essen-
Lukianowicz (1959) was perhaps the first investigator to tially opportunistic; (d) schizoid patients, who were analloerotic
devote significant attention to age of onset of gender dysphoria or asexual; and (e) eonists, who had minimal or no history of suc-
in describing transsexualism. Unlike some contemporaries, he cessful heterosexual relationships, homosexual experimentation,
distinguished between transvestism and transsexualism; he or sexual arousal with cross-dressing. The first four of these five
believed that, although the two conditions were similar, trans- sets of categories corresponded closely to Hirschfeld’s (1948)
sexualism was almost exclusively a male phenomenon and that homosexual, heterosexual, bisexual, and automonosexual/asex-
‘‘the morbid desire ‘to be a woman’ is much deeper in trans- ual groups; the fifth, eonists, consisted of persons who would later
sexualism’’(p. 50). Lukianowicz classified transvestites accord- be considered ‘‘classical’’ or ‘‘true’’ transsexuals in other typolo-
ing to sexual orientation (asexual, automonosexual, heterosex- gies. Interestingly, Meyer did not believe that an early onset of
ual, homosexual, or bisexual) but thought it‘‘likely that all transgender dysphoria was particularly characteristic of eonists, noting
sexualists are homosexual’’(p. 49). Consequently, his principal that‘‘the eonists do not have an early history (as nearly as can be
criterion for classifying transsexuals was severity of distress told during the course of evaluation) necessarily different from
(mild, intermediate, or severe); he noted that mild cases were that of others presenting for sex reassignment’’(p. 549).
likely to be satisfied with partial measures, whereas in severe
cases‘‘the individual would be satisfied with nothing else but a
complete conversion-operation’’(p. 50). Lukianowicz believed MtF Transsexual Typologies Emphasizing Sexual
that transvestism—and apparently most cases of transsexual- Orientation
ism, too—usually developed very early in life. He observed that,
for the male transvestite, ‘‘the beginning of his transvestite The MtF transsexual typologies discussed in this section empha-
tendencies is to be sought in his early childhood’’(p. 51) and that size sexual orientation and are summarized in Table 1. All of the
123
Table 1 Male-to-female transsexual typologies emphasizing sexual orientation
Author(s) Category names Age of onset Criterion used to Exclusive Childhood cross- Cross-gender Asexuality or
define age of onset androphilia gender behavior fetishism analloeroticism
Benjamin (1966) Type VI Early childhood Gender dysphoria Always Not discussed Never? Often
Type V Early childhood Sometimes Not discussed Never? Often
Type IV Early childhood Never Not discussed Rarely? Often
Arch Sex Behav (2010) 39:514–545
Money and Gaskin Effeminate-homosexual Usually prepubertal Cross-gender identity Always Always Never? Sometimes
(1970–1971) Transvestitic Usually prepubertal Never Rarely? Always Not discussed
Bentler (1976) Homosexual Usually childhood Feel self to be like Always Not discussed Sometimes Never?
Heterosexual Usually childhood a woman Never Not discussed Often Never?
Asexual Usually childhood Never Not discussed Sometimes Often?
Levine et al. (1976) Group A (homosexual) By adolescence Cross-gender identity Always Not discussed Not discussed Often?
Group B (nonhomosexual) By adolescence Never Not discussed Not discussed Often?
Blanchard (1985, 1988, Homosexuala Usually prepubertal Cross-gender wishes Almost always Almost always Rarely Rarely
1989a, b; Blanchard Heterosexuala Often prepubertal Never Sometimes Almost always Rarely
et al. 1987)
Bisexuala Often prepubertal Never Sometimes Almost always Rarely
Asexual/analloerotica Often prepubertal Never Sometimes Almost always Usually
Whitam (1987, 1997) Homosexual Early childhood Cross-gender behavior Always Always Never Almost never?
Heterosexual Around puberty Never Rarely? Often Sometimes
Lawrence (2005) Homosexual Usually childhood Wish to be the other sex Always Not discussed Sometimes Rarely
Heterosexual Usually childhood Never Not discussed Almost always Rarely
Bisexual Usually childhood Never Not discussed Almost always Rarely
Asexual Usually childhood Never Not discussed Almost always Almost always
Smith et al. (2005a, b) Homosexual Usually childhood Gender dysphoria Always Often? Sometimes Not discussed
Nonhomosexual Sometimes childhood Never Sometimes? Often Not discussed
Johansson et al. (2009) Homosexual Variable Wish to become the Always Not discussed Not discussed Not discussed
Nonhomosexual Variable opposite sex Never Not discussed Not discussed Not discussed
Note: An entry with a question mark denotes a probable answer
a
Blanchard (1989a) recommended using only two categories, homosexual and nonhomosexual, when describing small numbers of persons
517
123
518 Arch Sex Behav (2010) 39:514–545
earliest attempts to categorize MtF transsexualism typologically conventionally masculine. Like their effeminate-homosexual
were based on sexual orientation. This probably reflects the tra- counterparts, their cross-gender feelings emerged before pub-
dition, dating back to Hirschfeld (1991), of using sexual orien- erty. Money and Gaskin did not suggest that their typology
tation as a descriptor in transvestism. At first, MtF transsexual carried any prognostic significance.
typologies based on sexual orientation were apparently intended Bentler (1976) formulated a MtF transsexual typology based
only to facilitate concise clinical description. By the late 1980s, on questionnaire data from 42 MtF patients who had undergone
however, sexual orientation was sometimes considered to be a SRS. He categorized participants as homosexual if they had
prognostic indicator in MtF transsexualism as well. identified as homosexual before SRS and had never married;
Benjamin’s (1966)‘‘Sex Orientation Scale’’was arguably the only a few of these persons reported any sexual activity with
first formally proposed MtF transsexual typology. Benjamin female partners, but 23% reported sexual arousal with cross-
distinguished MtF transsexual types primarily on the basis of dressing. Bentler categorized participants as heterosexual if
severity of gender dysphoria, but sexual orientation also differed they had been married before SRS; all but one of these partici-
significantly between types. Benjamin recognized three types pants also had identified as heterosexual before SRS, and most
of male transvestism, which he called Types I, II, and III, along reported multiple female sexual partners, but only 50% reported
with three types of MtF transsexualism, which he called Types sexual arousal with cross-dressing. He categorized participants
IV, V, and VI. Benjamin’s Type VI MtF transsexuals were as asexual if they denied having identified as homosexual before
‘‘true’’transsexuals; they were severely gender dysphoric, and SRS, had never been married, and denied ever having experi-
their sexual orientation was always exclusively homosexual enced ‘‘pleasant and successful’’ coitus with female partners;
(Kinsey 6). Type V MtF transsexuals were also ‘‘true’’ trans- most of these individuals reported few female sexual partners,
sexuals, but were less severely gender dysphoric; their sexual about half had identified as heterosexual, and only 18% reported
orientation could range from bisexual to exclusively homosexual arousal with cross-dressing. Bentler believed that his
sexual (Kinsey 4–6). Benjamin did not consider Type IV MtF typology was clinically meaningful, noting that homosexual
transsexuals to be ‘‘true’’ transsexuals; he believed they rep- MtF transsexuals tended to undergo more surgical procedures
resented an intermediate stage between transvestism and than their heterosexual and asexual counterparts but often
‘‘true’’ transsexualism. Type IV MtF transsexuals were the seemed less satisfied with their results.
least gender dysphoric of the three transsexual types, and their Levine, Gruenewald, and Shaiova (1976) contrasted 12 MtF
sexual orientation could range from primarily heterosexual to transsexuals who had engaged in homosexual behavior exten-
bisexual (Kinsey 1–4; but apparently not Kinsey 0). Benjamin sively and regularly (group A) and 6 MtF transsexuals who had
thought that MtF transsexuals of all three types often displayed engaged in homosexual behavior infrequently, briefly, or not at
little sexual interest or exhibited low libido. He apparently did all (group B). Members of both groups reported feelings of
not consider age of onset of gender dysphoria to be important belonging to the opposite sex at least from adolescence. Levine
for distinguishing transsexual types: He noted that MtF trans- et al. observed that the groups differed most significantly in their
sexuals of all three types commonly reported the onset of employment history: All those in group A received public assis-
gender dysphoria in early childhood. tance, and all had worked as prostitutes, whereas all but one of
Money and Gaskin (1970–1971) proposed another early MtF those in group B were employed, and none were known to have
transsexual typology emphasizing sexual orientation, although engaged in prostitution. Moreover, the members of group A
they explicitly rejected the word ‘‘typology,’’ arguing that MtF uniformly‘‘expressed virtually no affect in their conversations’’
transsexualism represented a continuum of symptomatology. (p. 84), whereas most of those in group B displayed at least
Accordingly, they presented their proposed MtF transsexual ‘‘superficially more adequate, socially appropriate modulation
types—effeminate-homosexual and transvestitic—as ‘‘ideal- of emotional expressiveness’’(p. 84). The report by Levine et al.
ized cases,’’ rather than descriptors of distinct clinical popula- represents one of the earliest attempts to examine possible
tions. Money and Gaskin’s effeminate-homosexual MtF trans- relationships between sexual orientation and psychopathology
sexuals were overtly feminine in their interests and behaviors in MtF transsexualism.
during childhood and adulthood and were exclusively sexually Blanchard (1985, 1988, 1989a, b; Blanchard, Clemmensen,
attracted to men. The authors thought that the typical effemi- & Steiner, 1987) proposed a sexual orientation-based MtF trans-
nate-homosexual MtF transsexual was also hyposexual,‘‘essen- sexual typology that is now regarded as‘‘fundamental’’(Michel,
tially indifferent to his own orgasm, and perhaps even offended Mormont, & Legros, 2001, p. 366). Blanchard (1985) studied
by it’’ (p. 256). Money and Gaskin’s transvestitic MtF trans- the prevalence of sexual arousal with cross-dressing in 163 MtF
sexuals, like the transvestites they resembled, were heterosexual transsexuals, whom he divided into four groups—homosexual,
in orientation but also experienced cross-gender fetishism, heterosexual, bisexual, and asexual—based on their scores on
in that ‘‘male genital arousal and performance are, paradoxi- separate measures of androphilia (sexual attraction to adult
cally, dependent on the emergence of the feminine personal- males) and gynephilia (sexual attraction to adult females). Sig-
ity’’ (p. 255). Their gender expression was, at least at times, nificantly fewer of Blanchard’s homosexual participants (15%)
123
Arch Sex Behav (2010) 39:514–545 519
reported sexual arousal with cross-dressing than did the heter- Lawrence (2005) studied the sexual behavior of 232 MtF
osexual, bisexual, or asexual participants (73% combined), transsexuals who had undergone SRS. She categorized partic-
with no significant differences among the last three groups. ipants on the basis of sexual orientation but found that partici-
Blanchard believed that some instances in which ostensibly pants sometimes reported a significant change in the direction
homosexual participants reported sexual arousal with cross- of their sexual attraction after undergoing SRS. Lawrence
dressing were attributable to misrepresentation of sexual orien- also observed that three possible criteria for assigning sexual
tation by persons who were actually not androphilic. Blanchard orientation—stated sexual attraction, stated pattern of sexual
et al. (1987) found that the ages of onset of cross-gender wishes partnering, and reported numbers of male and female partners—
and cross-dressing did not differ significantly between homo- yielded slightly different results. For most analyses, Lawrence
sexual and heterosexual (i.e., not exclusively homosexual) MtF used the last of these criteria, classifying participants based on
transsexuals. Blanchard (1988) observed that homosexual MtF their sexual experience before SRS as homosexual (at least one
transsexuals reported significantly higher levels of cross-gender male partner and no female partners), heterosexual (at least one
wishes, feelings, and behaviors during childhood than did female partner and no male partners), bisexual (at least one male
nonhomosexual (i.e., not exclusively homosexual) MtF trans- and one female partner), or asexual or analloerotic (no female or
sexuals and that they sought treatment at significantly younger male partners). Lawrence observed that the prevalence of
ages. Blanchard (1989b) demonstrated that homosexual, heter- autogynephilic sexual arousal before SRS varied with sexual
osexual, bisexual, and asexual/analloerotic MtF transsexuals orientation: Heterosexual and bisexual participants reported a
could be differentiated based on formal measures of cross- significantly higher prevalence of any autogynephilic sexual
gender fetishism, heterosexual experience, analloeroticism, and arousal, and higher median levels of autogynephilic arousal,
autogynephilia (sexual arousal to the thought or image of one- than homosexual participants. There were also nonsignificant
self as a female). trends for asexual participants to report a higher prevalence of
Writing from a cross-cultural perspective, Whitam (1987, any autogynephilic arousal and a higher median level of auto-
1997) described homosexual MtF transsexuals as‘‘highly cross- gynephilic arousal than homosexual participants. A few osten-
gendered [male] individuals of homosexual orientation who live sibly homosexual participants reported autogynephilic sexual
much of the time as women and would prefer to be women arousal; in most cases, this seemed to reflect misrepresentation
regardless of whether sex reassignment surgery is sought’’ of their sexual orientation. Lawrence also found that the number
(Whitam, 1987, p. 183). He observed that ‘‘in most societies of sexual partners before SRS reported by homosexual, heter-
these persons regard themselves as homosexuals and are osexual, and bisexual participants were roughly comparable
regarded by more masculine homosexuals as a natural part of the to the number of lifetime sexual partners reported by male
homosexual world’’(Whitam, 1987, p. 177). Thus, for Whitam, participants in the National Health and Social Life Survey
homosexual MtF transsexuals were homosexual men with trans- (Laumann, Gagnon, Michael, & Michaels, 1994); if number of
sexual wishes and lifestyles, not MtF transsexuals whose partners can be considered an indicator of sexual interest, these
sexual orientation happened to be homosexual. He observed results suggested that homosexual, heterosexual, and bisexual
that homosexual MtF transsexuals usually engaged in overt MtF transsexualism did not represent hyposexual conditions.
cross-gender behavior beginning in early childhood, that they Smith, van Goozen, Kuiper, and Cohen-Kettenis (2005a, b)
did not exhibit cross-gender fetishism, and that they typically categorized MtF transsexual patients as homosexual or nonho-
displayed ‘‘strong, overt sexuality’’ (Whitam, 1997, p. 202). mosexual (i.e., not exclusively homosexual) on the basis of self-
Whitam (1987) described heterosexual MtF transsexuals as reported pattern of sexual attraction. Lawrence (2008a) argued
heterosexual men who ‘‘desire sex reassignment surgery but that, based on their marital histories, some MtF patients whom
do not have [behavioral] characteristics that are often linked Smith et al. (2005b) had described as homosexual had probably
to being female’’ (p. 197). He noted, for example, that het- misrepresented their sexual orientations and were actually non-
erosexual MtF transsexuals were often highly athletic, rarely homosexual, potentially blurring genuine differences between
engaged in dancing or performance, and tended to favor the two groups. Despite this possible limitation, Smith et al.
traditionally masculine occupations. He also stated that het- (2005b) observed that homosexual and nonhomosexual MtF
erosexual MtF transsexuals were usually typically masculine patients differed in significant ways: Compared with their non-
during childhood and that ‘‘often their only cross-gender homosexual counterparts, homosexual MtF patients sought
behavior is cross-dressing, which may not appear until just sex reassignment at younger ages, were less likely to report a
before, during, or after puberty and is often done in secret’’ history of sexual arousal with cross-dressing, were less likely to
(Whitam, 1997, p. 192). Whitam (1997) further observed that have been married, and were judged to have a physical appear-
heterosexual MtF transsexuals ‘‘often report cross-dressing ance that was more congruent with their gender identity. Homo-
fetishistically at least for a period of time’’ (p. 193) and that sexual MtF patients reported more symptoms of GID during
they ‘‘seem to manifest significantly lower levels of sexual childhood than their nonhomosexual counterparts, but this dif-
interest’’ (p. 202) than their homosexual MtF counterparts. ference was not statistically significant (Smith et al., 2005b).
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520 Arch Sex Behav (2010) 39:514–545
Two MtF patients expressed some regret following SRS; both transvestism’’ (p. 6). Person and Ovesey (1974a) believed that
were nonhomosexual (Smith et al., 2005a). primary MtF transsexualism began in early childhood, whereas
Johansson et al. (2009) summarized outcomes of the sex secondary MtF transsexualism developed in adulthood, usually
reassignment process in 25 male GID patients, whom they cate- in reaction to some severe psychosocial stress. Primary MtF
gorized on the basis of both sexual orientation (homosexual vs. transsexualism was supposedly characterized by a low level of
nonhomosexual) and age of onset of cross-gender wishes; I will sexual interest and by the absence of either overt masculinity or
address the former categorization here. The authors did not explic- effeminacy. Secondary transsexualism, as described by Person
itly describe their basis for deciding sexual orientation, but they and Ovesey (1974b), was not a unitary phenomenon: It encom-
referenced Blanchard (1989a), suggesting that they were famil- passed two distinct subtypes, homosexual and transvestitic,
iar with his system of categorization. Among 13 patients cate- closely resembling the subtypes that Money and Gaskin (1970–
gorized as homosexual, 1 had not yet completed SRS and 1 other 1971) called effeminate-homosexual and transvestitic. The only
had decided to forgo SRS entirely; among 12 patients catego- unifying feature of secondary transsexualism was its adult onset.
rized as nonhomosexual, 2 had not yet completed SRS and 3 Person and Ovesey (1974b) felt that:
others had decided to forego SRS (between-group differences
In terms of our classification, the primary transsexual
nonsignificant). All but 1 patient self-rated the global outcome
theoretically should make the best candidate for sex
of the sex reassignment process as positive; the exception, who
reassignment….The situation is different, however,
self-rated her outcome as negative, was nonhomosexual in ori-
with both homosexual and transvestic transsexuals who
entation. Clinicians rated the global outcomes of the homo-
comprise the majority of applicants for sex reassign-
sexual patients as positive in 10 cases and neutral in 3 cases; they
ment….We would…be extremely cautious in recom-
rated the global outcomes of the nonhomosexual patients as
mending surgical sex reassignment in these two groups
positive in 8 cases, neutral in two cases, and negative in 2 cases
(p. 191).
(neither of the last being the patient with the self-reported
negative outcome). Thus, all 3 instances of negative outcomes Fisk (1974a, b; Laub & Fisk, 1974) distinguished several types
(1 patient-rated, 2 clinician-rated) occurred in nonhomosexual of male patients who sought sex reassignment at the Stanford
MtF transsexuals (p = .10 by Fisher’s exact test, two-tailed). University gender program. He used the term gender dysphoria
syndrome, rather than transsexualism, to refer to these patients’
diagnosis. In Fisk’s typology, the number of recognized typo-
MtF Transsexual Typologies Emphasizing Age logical categories and their exact names varied slightly from one
of Onset of GID-Related Symptoms article to another. It appears that persons in only three of Fisk’s
typological categories, however, were considered appropriate
The MtF transsexual typologies discussed in this section, which candidates for SRS in the Stanford program (Laub & Fisk, 1974):
emphasize age of onset of GID-related symptoms, are sum- classic transsexualism of Benjamin (a reference to Benjamin,
marized in Table 2. The need to develop criteria for selecting 1966), effeminate homosexuality, and transvestism. Only patients
appropriate candidates for sex reassignment apparently inspired in these three categories, for example, were selected for inclusion
the development of many typologies emphasizing age of onset. in a follow-up descriptive study of applicants to the Stanford
Clinicians and researchers hypothesized that persons who program (Dixen, Maddever, Van Maasdam, & Edwards, 1984);
reported an early onset of GID-related symptoms were likely consequently, only these categories are included in Table 2. Other
to be better candidates for sex reassignment than persons who typological categories described by Fisk included persons with
reported a later onset of these symptoms (Person & Ovesey, psychosis, extreme sociopathy and psychopathy, and inadequate/
1974b). Patients who reported an early onset of GID-related schizoid personality (1974b; Laub & Fisk, 1974). Classic MtF
symptoms, therefore, were referred to as ‘‘primary,’’ ‘‘true,’’ transsexualism was characterized by onset in early childhood,
‘‘core,’’ or ‘‘genuine’’ transsexuals, whereas their counterparts life-long feminine behavior, exclusive androphilia, absence of
who reported a later onset were referred to as ‘‘secondary,’’ sexual arousal with cross-dressing, and perhaps a disinterest in
‘‘atypical,’’or‘‘non-core’’transsexuals. genital sexuality (Fisk, 1974a; Laub & Fisk, 1974). Effeminate
Person and Ovesey (1974a, b) proposed one of the most homosexuality progressing to gender dysphoria syndrome was
influential MtF transsexual typologies based on age of onset of characterized by androphilia, episodic nonerotic cross-dressing,
gender dysphoria (Michel et al., 2001, p. 366, described it as and onset of gender dysphoria in adulthood (Laub & Fisk, 1974).
‘‘fundamental’’), although it differed significantly from most Transvestism progressing to gender dysphoria syndrome was
age of onset-based typologies that followed. Person and Ovesey characterized by erotic arousal with cross-dressing, gynephilia,
(1974a) distinguished primary MtF transsexuals, in whom the and onset of gender dysphoria in adulthood (Laub & Fisk, 1974).
‘‘transsexual impulse’’(p. 6) was lifelong and unremitting, from Stoller (1979, 1980) began to formulate theories of MtF trans-
secondary MtF transsexuals,‘‘who gravitate toward transsexu- sexual development in the late 1960s (e.g., Stoller, 1968) but
alism only after sustained periods of active homosexuality or apparently did not propose a formal MtF transsexual typology
123
Table 2 Male-to-female transsexual typologies emphasizing age of onset
Author(s) Category names Age of onset Criterion used to Exclusive Childhood Cross-gender Asexuality or
define age of onset androphilia cross- fetishism analloeroticism
gender behavior
Person and Ovesey (1974a, Primary Early childhood Wish for sex reassignment Never? Rarely Never Always
b) Homosexuala Adulthood Always Always Never Never
Transvestitica Adulthood Never Never? Always Sometimes
Fisk (1974a, b; Laub Classic transsexualismb Early childhood Desire to be the other sex Always Always Never Often?
& Fisk 1974) Effeminate homosexualityb Adulthood Always Usually? Never Not discussed
Arch Sex Behav (2010) 39:514–545
Transvestismb Adulthood Never Never? Always Not discussed

Stoller (1979, 1980) Primary (true) Early childhood Complete and overt cross-gender behavior Always Always Never Not discussed
Secondary Usually Sometimes Sometimes Sometimes Not discussed
adulthood
Levine and Lothstein (1981) Primaryb Early childhood Cross-gender identity and gender Always Always Never Not discussed
Effeminate homosexuala,b Adulthood dysphoria Always Usually Never Not discussed
Transvestica,b Adulthood Never Never? Always Sometimes?
Gender ambiguousa,b Adulthood Never Sometimes? Not discussed Usually
Lundström et al. (1984) Primary (genuine) Childhood? Unremitting gender dysphoria Always Always Never Usually
a
Effeminate homosexuality Adulthood? Always Always Never Never?
Transvestisma Adulthood? Never Never Always Rarely?
Dolan (1987) Primary (true) Early childhood Cross-gender wishes and behavior Always Always Never Sometimes
Effeminate homosexuala Adulthood Always Always Never Not discussed
Heterosexual transvestitica Adulthood Never Never? Always Not discussed
Atypicala Adulthood Sometimes Not discussed Not discussed Sometimes
Docter (1988) Primary Early childhood Unremitting gender dysphoria Usually Usually Never Not discussed
Secondary, homosexual Adulthood Usually Sometimes? Never Not discussed
type
Secondary, transvestite type Adulthood Never Sometimes? Always Not discussed
Burns et al. (1990) Core positive Prepubertal Gender dysphoria or cross-gender Often Sometimes? Never Sometimes
Core negative Postpubertal behavior Sometimes Not discussed Sometimes Sometimes
Doorn et al. (1994) Early-onset Prepubertal Awareness of transsexual feelings Usually Often Sometimes Not discussed
Late-onset Postpubertal Sometimes Sometimes Often Not discussed
Seil (1996, 1997, 2004) Primary (ego-syntonic) Early childhood Overt expression of cross-gender identity Usually Always Never? Often
Secondary (ego-dystonic) Adulthood Sometimes Rarely? Often Often
Landén et al. (1998) Core Prepubertal? Unremitting gender dysphoria Always Always Never Not discussed
Non-core Postpubertal? Often Usually Sometimes Not discussed
521
123
522 Arch Sex Behav (2010) 39:514–545
analloeroticism
until 1979. He defined primary (or true) MtF transsexuals as those
Not discussed
Not discussed
Not discussed
Not discussed
Not discussed
Not discussed
Asexuality or
who were and always had been‘‘the most feminine of all males,
[who] have never had an episode—for moments or extended
periods—of being able to appear like or live in the role of
an ordinary masculine male’’ (1979, p. 541). Stoller (1980)
explained that ‘‘the word ‘primary’ is used in this diagnosis
Cross-gender fetishism
because the condition starts in the patient’s earliest years and

remains constant throughout life. It can, therefore, be contrasted
Not discussed
Not discussed
Not discussed
Not discussed with secondary transsexualism, a later acquisition’’ (p. 1699).
Thus, Stoller’s secondary MtF transsexuals were those who had
Never
Often
lived unequivocally as boys or men, at least for short periods.

Stoller (1980) recognized that there was great diversity among
secondary MtF transsexuals, and he considered the category to be
Childhood cross-
gender behavior
little more than ‘‘a wastebasket diagnosis’’ (p. 1700). Neverthe-

Not discussed
Not discussed
Not discussed
Sometimes?
less, he observed that secondary MtF transsexuals constituted‘‘by

far the greatest number of people requesting sex reassignment’’
Always
Always
(Stoller, 1980, p. 1701). Stoller noted that most of the patients that
Person and Ovesey (1974a) considered primary MtF transsexuals
would be categorized as secondary MtF transsexuals under his
Not discussed
typology. He believed that psychotherapy might result in some

androphilia
Sometimes
Sometimes
Exclusive
Usually?
secondary MtF transsexuals giving up their wish for sex reas-

Always
Never?
The authors referred to these as categories of gender dysphoria syndrome, rather than categories of transsexualism
signment, whereas this was unlikely in the case of primary MtF

transsexuals.
Levine and Lothstein (1981) described males with primary
Wish to become the opposite sex
gender dysphoria syndrome as having an‘‘obvious, document-

Unrmitting gender dysphoria
Meeting full criteria for GID
able, lifelong, profound disturbance of core gender identity’’

(p. 88), characterized in childhood by relentless cross-dressing
(albeit perhaps secretly) and overt effeminacy and in adoles-
define age of onset
Criterion used to
cence by a complete absence of cross-gender fetishism or het-

erosexual experimentation. Any adolescent homosexual experi-
A subtype of secondary transsexualism or secondary gender dysphoria syndrome
mentation by these individuals was supposedly‘‘short-lived and

unpleasant’’ (p. 88), resulting in rejection of homosexual iden-
tity. Levine and Lothstein noted, however, that‘‘many of these
[primary] patients report brief, unsuccessful, last-ditch efforts to
Early childhood
Early childhood
live as males in mid- to late adolescence’’ (p. 89). The authors

Age of onset
Postpubertal
Adulthood?
Adulthood?
Childhood
thought that only a few males requesting sex reassignment were

of the primary type. Like Person and Ovesey (1974a, b), Levine
and Lothstein believed that secondary gender dysphoria syn-
drome arose later in life, presumably in adulthood. Males with
Category names
secondary gender dysphoria syndrome had also experienced

Early-onset
Early-onset
lifelong gender identity concerns, but of lesser intensity; they

Late-onset
Late-onset
Secondary
Primary
were more conflicted about their feminine identifications and

tended to be more overtly masculine in their presentations.
Levine and Lothstein thought that secondary gender dysphoria
syndrome could arise from any of three prototypical adapta-
Herman-Jeglińska et al. (2002)
tions to these lower-intensity gender identity concerns: effemi-

nate homosexual, characterized by exclusive or near-exclusive
Johansson et al. (2009)
Haraldsen et al. (2003)
androphilia and childhood effeminacy; transvestic, character-

Table 2 continued
ized by gynephilia and a history of cross-gender fetishism;

and gender ambiguous, characterized by bisexuality and low
Author(s)
libido. There was also a mixed adaptation (not listed in Table 2),
combining features of two or more of the prototypical adapta-
tions. Levine and Lothstein observed that the development of
b
a
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Arch Sex Behav (2010) 39:514–545 523
secondary gender dysphoria syndrome from one of these transition. He observed that most published case reports of regret
adaptations was usually related to stress (e.g., loss of an impor- following MtF sex reassignment involved secondary transsex-
tant relationship, severe depression, or physical disease). uals.
Lundström, Pauly, and Wålinder (1984) distinguished between Docter (1988) likewise distinguished primary (early-onset)
primary (genuine) and secondary transsexualism in males. and secondary (late-onset) MtF transsexualism, proposing that
Although Lundström et al. did not use the term‘‘age of onset’’or ‘‘the critical component that sets [primary MtF transsexualism]
any similar term, they believed that the critical distinguishing apart from all others is the necessary history of lifelong gender
characteristic of primary MtF transsexualism was the absence of dysphoric feelings’’ (pp. 24–25). He added, however, that pri-
any‘‘fluctuation in gender dysphoria symptoms’’(p. 292), which mary MtF transsexualism was typically accompanied by ‘‘sex-
implied an early onset—presumably in childhood, although this ual preference [that] is usually homosexual from an early age’’
was not explicitly stated—of gender dysphoria that then remained (p. 24),‘‘an absence of fetishism associated with cross dressing’’
consistently present over the person’s entire life. Weak libido and (p. 24), and‘‘actual behavior which is more appropriate for the
an intense aversion to biological sex characteristics were also opposite gender’’ (p. 27). Docter believed that secondary MtF
prominent features of primary MtF transsexualism. In addition, transsexualism comprised two different subtypes, of which‘‘one
primary MtF transsexuals invariably had been feminine as chil- is based on a [prior] career as a transvestite and the other is based
dren, were androphilic, and lacked any history of fetishistic cross- on a prior career as a homosexual’’(p. 29). He thought that the
dressing. Like Person and Ovesey (1974a, b), Lundström et al. two secondary MtF subtypes shared ‘‘an absence of lifelong
believed that there were two distinct subtypes of secondary MtF gender dysphoria’’ and ‘‘features of narcissistic or borderline
transsexualism, arising from either effeminate homosexuality or personality’’ (p. 29) but few other features in common. Sec-
transvestism; the feature shared by these two subtypes was fluc- ondary MtF transsexualism, homosexual type, was character-
tuation in gender dysphoria over the person’s life. Secondary MtF ized by ‘‘predominantly homosexual erotic preference’’ (p. 32)
transsexualism arising from effeminate homosexuality was char- and no history of fetishistic cross-dressing. Secondary MtF trans-
acterized by androphilia, childhood effeminacy, no history of fetish- sexualism, transvestite type, was characterized by a history of
istic cross-dressing, and libido that was ‘‘often high’’ (p. 292). sexual arousal with cross-dressing and a heterosexual or bisexual
Secondary MtF transsexualism arising from transvestism was erotic preference.
characterized by a history of fetishistic cross-dressing, gynephilia, Burns, Farrell, and Brown (1990) conducted a retrospective
and absence of childhood effeminacy. Lundström et al. believed chart review of patients who had applied for sex reassignment at
that‘‘most gender dysphoric patients are secondary transsexuals, a gender identity clinic in London. They distinguished between
who will not be helped by sex reassignment’’(p. 290). core positive and core negative MtF transsexualism. Core
Dolan (1987) similarly distinguished between primary (true) positive MtF transsexuals were those who met the following
and secondary MtF transsexualism. He described primary MtF criteria: ‘‘(a) the age of onset was before puberty; (b) the adop-
transsexuals as those who displayed ‘‘lifelong cross-gender tion of the cross-gender role was without sexual arousal; and (c)
wishes and behaviour’’ (p. 667), were exclusively androphilic, a dislike of secondary sex characteristics was present’’(pp. 265–
and experienced no cross-gender fetishism; the extent of their 266). Patients not meeting these criteria were considered core
sexual interest was variable. Dolan was unusual in believing that negative. Burns et al. defined age of onset as‘‘the age at which
primary MtF transsexuals rarely cross-dressed before adoles- gender dysphoria and/or cross-gender behavior [emphasis
cence. He also asserted that they invariably passed effortlessly added] occurred which was related to the presenting problem’’
as females, without the benefit of cross-sex hormone therapy, (p. 266). Onset before age 13 was considered prepubertal.
electrolysis, or voice training. Dolan believed that primary MtF Although age of onset was not the only stated criterion in their
transsexuals were very rare. He described secondary MtF trans- typology, Burns et al. found that it was the key criterion: In a
sexuals, a residual group, as developing cross-gender wishes group of 25 MtF and 10 FtM transsexuals who met full DSM-III-
later in life. Dolan observed that there were three principal sub- R (APA, 1987) diagnostic criteria for transsexualism, age of
types of secondary MtF transsexualism. The effeminate homo- onset was the only characteristic on which core positive and core
sexual subtype was characterized by exclusive androphilia, negative patients differed significantly. Sexual arousal with
effeminacy, and nonerotic cross-dressing. The heterosexual cross-dressing, sexual orientation, and extent of sexual activity
transvestitic subtype was characterized by gynephilia, a history did not significantly differentiate between core positive and core
of fetishistic cross-dressing, and an absence of overt effeminacy. negative patients. Dislike of secondary sex characteristics
The atypical subtype comprised persons with diverse sexual ‘‘proved difficult to measure’’ (p. 266) and the authors appar-
orientations and backgrounds; psychiatric disorders, especially ently abandoned it as a criterion. Burns et al. found that core
borderline personality disorder, were common in this subtype. positive patients were more likely to be referred for SRS than
Dolan felt that sex reassignment was appropriate for primary core negative patients, although they did not report results
MtF transsexuals but risky for secondary MtF transsexuals, who for MtF and FtM transsexuals separately. Because the criteria
often lost their families, friends, and occupations following Burns et al. used in defining their typological categories
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524 Arch Sex Behav (2010) 39:514–545
probably were regarded as prognostically important by the cli- Seil (2004) reported that, among his 220 MtF patients, about
nicians making the referrals for SRS, this observation is not 76% of primary MtF transsexuals and 53% of secondary MtF
surprising. transsexuals reported being homosexual relative to birth sex,
Doorn et al. (1994) distinguished between early-onset and despite the fact that 65% of the secondary MtF transsexuals had
late-onset MtF transsexualism. They categorized MtF trans- been married to women. He suggested that many secondary MtF
sexuals who reported being‘‘aware of their transsexual feelings’’ transsexuals who had married women were ‘‘not very sexually
(p. 189) before age 12 as early-onset and those who reported active, and some marriages are almost celibate’’ (Seil, 2004,
awareness after age 12 as late-onset. In a group of 155 MtF p. 107) but that fetishistic cross-dressing occurred‘‘commonly’’
transsexual patients, Doorn et al. found that, in comparison to (Seil, 1996, p. 753) among secondary MtF transsexuals.
their late-onset counterparts, early-onset MtF patients reported a Landén et al. (1998) distinguished between core and non-
significantly greater preference for female-typical toys and play core MtF transsexualism, using criteria similar to those
activities during childhood (but no significant difference in employed by Lundström et al. (1984) but omitting the criterion
preference for girls as playmates), a significantly earlier age of of low sexual interest. The authors apparently agreed with
first cross-dressing (but no significant difference in frequency of Lundström et al. that the key defining features of core MtF trans-
adolescent cross-dressing or extent of fetishistic cross-dress- sexualism were unremitting gender dysphoria and aversion to
ing), and a significantly greater preference for imagined heter- biological sex characteristics. Landén et al.’s tabular data sug-
osexual male sexual partners in adolescence (but no significant gested that age of onset was probably prepubertal in most core
difference in overall level of sexual interest). MtF transsexuals but probably postpubertal in most of their non-
Seil (1996, 1997, 2004) proposed a MtF transsexual typology core counterparts. Core MtF transsexuals, as defined by Landén
that was nominally based on whether the patient’s cross-gender et al., were also exclusively homosexual, exhibited effeminate
wishes were experienced during childhood as nonconflictual behavior in childhood, and did not experience sexual arousal
(primary or ego-syntonic MtF transsexualism) or as conflictual with cross-dressing; but some non-core MtF patients also dis-
(secondary or ego-dystonic MtF transsexualism). Nevertheless, played these characteristics. Non-core MtF transsexuals, accord-
Seil’s typology closely resembled other typologies based on age ing to Landén et al., included at least two subgroups,‘‘conditions
of onset, in that overt cross-gender expression began in early bordering on transvestism’’and‘‘conditions bordering on homo-
childhood among primary MtF transsexuals but only in adult- sexuality’’(p. 285). In a combined group of MtF and FtM patients,
hood among secondary MtF transsexuals. Consequently, Seil’s Landén et al. found that core transsexuals were less likely than
typology can conveniently be grouped with typologies based non-core transsexuals to experience regret following SRS.
explicitly on age of onset. Seil (1996) believed, however, that Herman-Jeglińska et al. (2002) classified MtF transsexuals as
both primary and secondary MtF transsexuals first experienced primary or secondary, ostensibly using criteria identical to those
cross-gender wishes ‘‘at about the same age, 5 or 6 years’’ used by Landén et al. (1998) to differentiate core and non-core
(p. 753) and differed only in the extent to which those wishes MtF transsexualism. This might imply that, like Landén et al.,
created mental conflict, resulting in differences in overt cross- Herman-Jeglińska et al. also regarded the early onset of unre-
gender expression. Seil (1997) reported that‘‘during treatment, mitting gender dysphoria, accompanied by intense aversion to
secondary transsexuals are able to overcome the amnesia of biological sex characteristics, as the most significant defining
their early years and recall awareness and behavior indicative of features of primary MtF transsexualism. Sexual orientation also
gender dysphoria in the same developmental period reported by effectively differentiated the two groups, however, in that all
the primary transsexuals, i.e., around age five’’ (p. 137). Seil primary MtF transsexuals studied by Herman-Jeglińska et al.
(2004) proposed that parental disapproval of cross-gender expres- were exclusively homosexual, whereas no secondary MtF
sion, which was later internalized by the child, was the cause of transsexuals were. Moreover, Herman-Jeglińska et al. observed
the ego-dystonic feelings that secondary MtF transsexuals expe- that, in addition to cross-gender identity, the characteristic fea-
riencedinrelationtotheircross-genderwishes.Heconceded,how- tures of secondary transsexualism were‘‘behaviors bordering on
ever, that primary MtF transsexuals probably also encoun- transvestism (fetishistic cross-dressing) or a nonhomosexual…
tered parental disapproval and that the relative strength sexual orientation’’ (p. 529). Consequently, whereas the intel-
of cross-gender identity in the two groups might also be lectual pedigree of the MtF transsexual typology used by Her-
relevant: man-Jeglińska et al. emphasized age of onset, their typology
could equally well be interpreted as emphasizing sexual orien-
Why this disapproval is effective in suppressing gender tation. Herman-Jeglińska et al. found that, compared with their
identity for the secondary group of patients and not for the secondary counterparts, primary MtF transsexuals were sig-
primary group is not clear. It may be that the cross-gen- nificantly younger at clinical presentation and were significantly
dered identity is not as strong or clear for the secondary less likely to have been married; they also rated themselves as
group as it is for the primary transgendered. (2004, p. 106) significantly more feminine than secondary MtF transsexuals.
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Arch Sex Behav (2010) 39:514–545 525
Haraldsen et al. (2003) studied cognitive performance in histories of cross-gender fetishism. The fetishistic group
early-onset GID patients of both sexes. They defined early-onset reported significantly more heterosexual experience than the
patients as those‘‘fulfilling criteria A to D [for GID] in the DSM nuclear group; there was also a nonsignificant trend toward less
from childhood on’’ (p. 908). Otherwise, their description of homosexual experience in the fetishistic group. One member of
early-onset MtF patients was limited to the observation that their the fetishistic group appeared to have been primarily anallo-
cognitive performance did not differ from that of nontranssexual erotic. The authors used penile plethysmography to assess sex-
men. Haraldsen et al. observed that, among 52 early-onset ual orientation in the two groups; based on the summary data
patients of both sexes (22 males, 30 females), sexual orientation presented, most members of the nuclear group appeared to have
was primarily homosexual (n = 38) but occasionally hetero- been primarily androphilic, whereas most members of the
sexual (n = 2), bisexual (n = 3), or analloerotic (n = 9). Har- fetishistic group, with one notable exception, appeared to have
aldsen et al. did not describe any late-onset MtF patients nor any been primarily gynephilic. In an earlier report, Buhrich and
general characteristics of such patients. McConaghy (1977) described the histories of the fetishistic MtF
As previously noted, Johansson et al. (2009) categorized 25 patients in greater detail: All of the fetishistic MtF patients
male GID patients on the basis of both sexual orientation and age reported symptoms of gender dysphoria and gender-atypical
of onset of cross-gender wishes; I will address the latter cate- behavior during childhood.
gorization here. Johansson et al. did not explicitly describe their Sørensen and Hertoft (1980, 1982) were arguably the earliest
basis for deciding age of onset but suggested that a childhood researchers to distinguish between core and non-core MtF
onset of the ‘‘strong wish to become the opposite sex’’ was transsexualism. They defined these categories differently than
usually considered typical of early-onset transsexuals, whereas most subsequent investigators, however, so it is useful to con-
a pubertal or postpubertal onset (age 12 or later) of cross-gender sider their criteria carefully. Sørensen and Hertoft (1980)
identification and gender dysphoria was considered character- believed that core MtF transsexuals displayed intact reality test-
istic of late-onset transsexuals. All 11 patients categorized as ing, ‘‘stable, submissive, pseudofeminine narcissism’’ (p. 143),
early-onset had completed SRS; of 14 patients categorized as stable ego strength, and‘‘agenitalism’’(absence of genital sexual
late-onset, 3 had not yet completed SRS and 4 others had satisfaction; p. 143). The last of these criteria was perhaps the
decided to forego SRS entirely (p = .11 by Fisher’s exact test, most important typologically: None of Sørensen and Hertoft’s
two-tailed, for decision to forego SRS). The only patient who (1980) core MtF patients reported genital sexual satisfaction,
self-rated the global outcome of the sex reassignment process as but about 72% of their non-core MtF patients did. Sexual ori-
negative was early-onset. Clinicians rated the global outcomes entation did not distinguish between core and non-core MtF
of the early-onset patients as positive in 8 cases and neutral in 3 transsexuals: Most persons in both groups reported homosexual
cases and the global outcomes of the late-onset patients as attraction, and a few in both groups reported heterosexual attrac-
positive in 10 cases, neutral in 2 cases, and negative in 2 cases. tion. Sørensen and Hertoft (1982) observed that neither core nor
There were no significant between-group differences in global non-core MtF patients recalled any fetishistic cross-dressing.
outcome ratings. The authors believed that transsexualism began in early child-
hood in both groups.
Freund et al. (1982) studied 136 male patients with self-
MtF Transsexual Typologies Emphasizing Neither reported cross-gender identities; about three quarters were MtF
Sexual Orientation Nor Age of Onset transsexuals (with sustained cross-gender identities), while
the rest were ‘‘borderline transsexuals’’ (with fluctuating cross-
The three MtF transsexual typologies discussed in this section gender identities) or transvestites (with cross-gender identities
emphasize neither sexual orientation nor age of onset, but they only when sexually aroused). Freund et al. used the absence or
deserve consideration because of their historical or conceptual presence of self-reported cross-gender fetishism to distinguish
significance; these typologies are summarized in Table 3. Two between nonfetishistic (type A) and fetishistic (type B) trans-
of the typologies (Buhrich & McConaghy, 1977, 1978; Freund sexual categories. The patients’ sexual orientations were cate-
et al., 1982) emphasize cross-gender fetishism; these typologies gorized as homosexual or heterosexual, based on the relative
are closely associated with, but can be distinguished from, MtF strength of self-reported androphilia and gynephilia; thus, Fre-
typologies that emphasize sexual orientation. The typology pro- und et al.’s homosexual MtF transsexuals were predominantly,
posed by Sørensen and Hertoft (1980, 1982) is important pri- but not necessarily exclusively, homosexual. Sexual orientation,
marily because it was apparently the earliest typology to employ defined in this way, differed significantly between the two trans-
the term core transsexualism, a term that was subsequently used sexual types: Nonfetishistic MtF transsexuals, with rare excep-
by other investigators in rather different ways. tions, had predominantly homosexual orientations, whereas
Buhrich and McConaghy (1978) studied 29 MtF transsexual fetishistic MtF transsexuals displayed roughly equal numbers
patients and distinguished between a nuclear (nonfetishistic) of predominantly homosexual and predominantly heterosex-
group and a fetishistic group, based on the patients’ self-reported ual orientations. About three quarters of all predominantly
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526 Arch Sex Behav (2010) 39:514–545
analloeroticism
homosexual MtF transsexuals studied, however, were nonfe-
Not discussed
Not discussed
Asexuality or
tishistic. Moreover, predominantly homosexual MtF transsexu-
Sometimes
Sometimes
als who were fetishistic displayed significantly higher attraction
Rarely?
Always
to females and significantly lower attraction to males than pre-
dominantly homosexual MtF transsexuals who were nonfetish-
istic (i.e., fetishistic homosexual patients tended to be more
Cross-gender
bisexual, whereas nonfetishistic homosexual patients tended to

fetishism
Always
Always
be more predominantly homosexual). The childhood attitudes
Never?
Never?
Never
Never
and interests of the nonfetishistic MtF transsexuals were signif-
icantly more gender-atypical than those of their fetishistic coun-
terparts.
Childhood cross-
gender behavior
Not discussed
Not discussed
Not discussed
Usually
Often?
Often?
FtM Transsexual Typologies
The FtM transsexual typologies discussed in this section are

androphilia
Exclusive
Usually?
summarized in Table 4. Many early theorists argued that typol-

Rarely?
Rarely
Often
Often
Often
ogies for FtM transsexualism were unnecessary, because they

believed that essentially all FtM transsexuals shared whatever
typological characteristics were considered important. Thus,
Wish to be the opposite sex
Money and Gaskin (1970–1971) and Whitam (1987, 1997),

Cross-gender identity
who proposed MtF transsexual typologies based on sexual ori-

define age of onset
entation, believed that no such typology was required for FtM

Criterion used to
transsexuals, because all or almost all FtM transsexuals were

Not discussed
Table 3 Male-to-female transsexual typologies emphasizing neither sexual orientation nor age of onset
homosexual relative to birth sex. Similarly, Fisk (1974a, b; Laub

& Fisk, 1974) and Stoller (1979, 1980), who proposed MtF
transsexual typologies based on age of onset, believed that such
a typology was not required for FtM transsexuals, because FtM
transsexualism always developed in early childhood. Person
Early childhood
Early childhood
Not discussed
Not discussed
Age of onset
and Ovesey (1974a, b), who likewise framed a MtF transsexual

Childhood?
Childhood
typology based on age of onset, also concluded that such

a typology was unnecessary for FtM transsexuals; but they
believed that FtM transsexualism developed only in homosex-
ual females and, consequently, that all FtM transsexuals were of
Nonfetishistic (type A)
the late-onset or secondary type. Sørensen and Hertoft (1980,

Fetishistic (type B)
Fetishistic (type B)
1982), who proposed a MtF transsexual typology that empha-

Nuclear (type A)
Category names
sized the presence or absence of genital sexual interest, thought

that such a typology was unnecessary for FtM transsexuals,
Non-core
because‘‘all the females are genitally directed, [and] libidinally

Core
impulsive’’(p. 145).
Other authors were unclear or uncertain about whether a
typology for FtM transsexualism was indicated. Lundström
Buhrich and McConaghy (1977, 1978)
et al. (1984), who distinguished between primary and secondary

Sørensen and Hertoft (1980, 1982)
MtF transsexualism based on the presence or absence of life-

long, unwavering gender dysphoria, never clearly stated whe-
ther their typology was also applicable to FtM transsexuals:
Some language in their article seemed to imply this, but the
Freund et al. (1982)
authors never explicitly described a FtM typology or any cor-

related features. Blanchard (1989a), who proposed a MtF
Author(s)
transsexual typology based on sexual orientation, applied the

terms homosexual and nonhomosexual to FtM transsexuals
in a descriptive sense but stopped short of proposing a FtM
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Arch Sex Behav (2010) 39:514–545 527
typology based on sexual orientation, because he felt that clin- of secondary FtM transsexualism. The butch type homosexual
ical experience with nonhomosexual FtM transsexuals was so subtype was characterized by a history of childhood masculinity
limited that it was not possible to decide whether they shared and exclusive gynephilia; this was by far the most common of all
enough similarities to constitute a genuine type. Coleman, the subtypes. The‘‘transvestitic’’subtype was very rare and was
Bockting, and Gooren (1993) applied the terms bisexual and characterized by fetishistic cross-dressing or ‘‘overidealized
homosexual (referenced to gender identity, not birth sex) descrip- attachment’’ (p. 669) to male clothing, usually with prominent
tively to FtM transsexuals who were not exclusively gynephilic exhibitionistic traits; bisexuality and a history of childhood
but argued that a typological classification was not clinically masculinity were often present as well. The atypical subtype
useful, because ‘‘for female-to-male transsexuals, classification comprised females with varying sexual orientations and back-
based on sexual orientation does not seem relevant in clinical- grounds who usually had a history of borderline personality
decision making as to sex reassignment’’(p. 48). disorder or other major psychiatric illness.
A few researchers and clinicians, however, proposed formal Burns et al. (1990) distinguished between core positive and
FtM transsexual typologies, based on either sexual orientation core negative FtM transsexualism, as they had done for MtF
or age of onset of GID-related symptoms. Usually, these were transsexualism. Because none of the FtM transsexuals reported
extensions of typologies the authors had also proposed for MtF sexual arousal with cross-dressing, the principal criterion for
transsexuals. The extension of these typologies to FtM trans- distinguishing core positive from core negative persons was the
sexuals, however, often occurred with little explanation or elab- onset of gender dysphoria or cross-gender behavior before
oration and sometimes seemed to be almost an afterthought. versus after puberty. As noted earlier, Burns et al. found that core
Levine and Lothstein (1981) believed that the distinction positive patients were more likely than core negative patients to
between primary and secondary gender dysphoria syndrome was be referred for SRS, but they did not report results for MtF and
applicable to females as well as males. They described females FtM transsexuals separately.
with primary gender dysphoria syndrome as having obvious Seil (1996, 1997, 2004) applied his distinction between
masculine personality characteristics that had been present since primary (ego-syntonic) and secondary (ego-dystonic) transsex-
childhood and that were relentlessly progressive. Levine and ualism to FtM transsexuals. As noted earlier, he believed that
Lothstein thought that most females with gender dysphoria syn- parental disapproval of cross-gender expression, subsequently
drome were of the primary type. They observed that sexual ori- internalized by the child, accounted for the ego-dystonic feel-
entation in females with primary gender dysphoria syndrome was ings that secondary transsexuals, both MtF and FtM, experi-
‘‘often’’ (p. 96), but apparently not always, exclusively gyne- enced with respect to their cross-gender feelings. Seil (1996)
philic. Levine and Lothstein believed that secondary gender conceded, however, that cross-gender expression by females
dysphoria syndrome in females was characterized by a ‘‘pro- often elicited little disapproval, noting that a gender-atypical girl
gression of masculine behaviors [that] is not relentless’’ (p. 96). might‘‘attain the niche of family tomboy, often to the delight of
They thought it could arise from either of two prototypical adap- the father’’(p. 751) and that‘‘a masculine young woman can find
tations to ongoing gender identity concerns: homosexual, char- an acceptable place in adolescent society’’(p. 751). These obser-
acterized by masculinity and gynephilia, often in the context vations might suggest that secondary FtM transsexualism would
of recent object loss and a‘‘rigidly antihomosexual background’’ be a rare phenomenon; but, unlike most other investigators, Seil
(p. 96); and gender ambiguous, characterized by less obvious (2004) thought that the majority of his FtM patients were sec-
masculinity and an absence of exclusive gynephilia. As with secondary or ego-dystonic. He reported that about 90% of his pri-
ondary gender dysphoria syndrome in males, there was also a mary FtM transsexual patients were gynephilic, as were about
mixed adaptation (not listed in Table 4), combining features of the 75% of his secondary FtM transsexual patients.
two prototypical adaptations. Levine and Lothstein appeared to In a study of cognitive functioning in FtM and MtF trans-
doubt that cross-gender fetishism was relevant to understanding sexual patients, Cohen-Kettenis et al. (1998) extended Doorn
gender dysphoria syndrome in females, suggesting that‘‘there is et al.’s (1994) typology of MtF transsexualism to FtM trans-
probably no such thing as a female transvestite’’(p. 95). sexuals, distinguishing between early-onset and late-onset sub-
Dolan (1987) similarly extended his typology of primary types. Cohen-Kettenis et al. confined their investigation to
(true) and secondary transsexualism to FtM transsexuals. He early-onset transsexuals: They neither described any late-onset
described primary FtM transsexuals as displaying cross-gender FtM patients nor discussed any general characteristics of such
wishes and behaviors from earliest childhood, being exclusively patients. Cohen-Kettenis et al. described early-onset FtM trans-
gynephilic, and never experiencing cross-gender fetishism. He sexuals only briefly, noting that all were homosexual in orien-
believed that FtM transsexuals of this type were quite rare. tation and that they achieved worse scores than nontranssexual
Dolan believed that primary FtM transsexuals could pass easily women on a test of verbal memory but similar scores on tests of
as men without the use of cross-sex hormones. He described visuospatial ability.
secondary FtM transsexuals as developing cross-gender wishes Landén et al. (1998) distinguished between core and non-
later in life. Dolan believed there were three principal subtypes core FtM transsexuals, just as they did for MtF transsexuals. As
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528
Table 4 Female-to-male transsexual typologies
123
Author(s) Category names Age of onset Criterion used to Exclusive Childhood cross- Cross-gender Asexuality or
define age of onset gynephilia gender behavior fetishism analloeroticism
Levine and Lothstein (1981) Primarya Early childhood Cross-gender identity and Always Always Never Not discussed
a,b gender dysphoria
Homosexual Adulthood Always Usually? Never Not discussed
Gender ambiguousa,b Adulthood Never? Not discussed Never Not discussed
Dolan (1987) Primary (true) Early childhood Cross-gender wishes Always Always Never Sometimes
Butch type homosexualb Adulthood and behavior Always Always Never Not discussed
‘‘Transvestitic’’b Adulthood Never Often Sometimes? Not discussed
Atypicalb Adulthood Sometimes Not discussed Not discussed Not discussed
Burns et al. (1990) Core positive Prepubertal Gender dysphoria or Often Sometimes? Never Sometimes?
Core negative Postpubertal cross-gender behavior Often Not discussed Never Sometimes?
Seil (1996, 1997, 2004) Primary (ego-syntonic) Early childhood Overt expression of Almost always Always Not discussed Not discussed
Secondary (ego-dystonic) Adulthood cross-gender identity Usually Often? Not discussed Sometimes?
Cohen-Kettenis et al. (1998) Early-onset Prepubertal Awareness of transsexual Always Usually? Not discussed Not discussed
Late-onset Postpubertal feelings Not discussed Not discussed Not discussed Not discussed
Landén et al. (1998) Core Prepubertal? Unremitting gender dysphoria Always Always Never Not discussed
Non-core Postpubertal Often Usually Never Not discussed
Chivers and Bailey (2000) Homosexual Childhood Cross-gender identity Usually Always? Not discussed Not discussed
Nonhomosexual Childhood Never Usually? Not discussed Not discussed
Herman-Jeglińska et al. (2002) Primary Early childhood Unremitting gender dysphoria Always Always Never Not discussed
Secondary Adulthood? Never? Sometimes? Not discussed Not discussed
Haraldsen et al. (2003) Early-onset Childhood Meeting full criteria for GID Usually? Always Not discussed Not discussed
Late-onset Adulthood? Not discussed Not discussed Not discussed Not discussed
Smith et al. (2005a, b) Homosexual Not specified Gender dysphoria Always Almost always? Rarely Not discussed
Nonhomosexual Not specified Never Almost always? Rarely Not discussed
Johansson et al. (2009) Homosexual Usually childhood Wish to become the opposite sex Always Not discussed Not discussed Not discussed
Nonhomosexual Variable Never Not discussed Not discussed Not discussed
Johansson et al. (2009) Early-onset Early childhood Wish to become the opposite sex Almost always? Not discussed Not discussed Not discussed
Late-onset Postpubertal Sometimes Not discussed Not discussed Not discussed
a
The authors referred to these as categories of gender dysphoria syndrome, rather than categories of transsexualism
b
A subtype of secondary transsexualism or secondary gender dysphoria syndrome
Arch Sex Behav (2010) 39:514–545
Arch Sex Behav (2010) 39:514–545 529
previously noted, their criteria were similar to those of patients. For FtM and MtF patients combined, sexual orienta-
Lundström etal.(1984). UnlikeLundström et al.,however,Landén tion was primarily, but not exclusively, homosexual.
et al. clearly indicated that their typology was applicable to FtM Smith et al. (2005a, b) categorized FtM transsexuals as homo-
transsexuals (e.g., in a footnote to their Table 1, p. 286), although sexual or nonhomosexual on the basis of self-reported sexual
their descriptions of the criteria for distinguishing between core attraction. Smith et al. (2005b) found that homosexual and non-
and non-core individuals were not always appropriate for FtM homosexual FtM patients did not differ significantly in the age at
persons (e.g., one was the presence or absence of ‘‘effeminate which they sought sex reassignment, history of marriage, or
behavior during childhood,’’p. 285). The characteristic features congruence of their physical appearance with their gender iden-
of core FtM transsexualism were unremitting gender dysphoria, tity. Although homosexual FtM patients reported more symp-
aversion to biological sex characteristics, homosexual orienta- toms of GID during childhood than their nonhomosexual coun-
tion, absence of sexual arousal with cross-dressing, and child- terparts, the difference was not statistically significant. Homo-
hood cross-gender behavior (being a ‘‘tomboy’’; p. 286). The sexual FtM patients did, however, report significantly fewer
authors found no evidence of sexual arousal with cross-dressing psychological problems than did nonhomosexual FtM patients.
in any of their FtM patients, however, and their tabular data Johansson et al. (2009) summarized outcomes of the sex reas-
suggested that cross-gender behavior during childhood was signment process in 17 female GID patients, whom they cate-
present in nearly all FtM transsexuals. Based on Landén et al.’s gorized on the basis of both sexual orientation (homosexual vs.
tabular data, age of onset was probably prepubertal in most core nonhomosexual) and age of onset of the wish to become the oppo-
FtM transsexuals but postpubertal in most non-core FtM trans- site sex; consequently, this study is assigned two separate entries
sexuals. As previously noted, Landén et al. found that, for MtF in Table 4. As previously noted, the authors did not explicitly
and FtM patients combined, core transsexuals were less likely describe their bases for deciding sexual orientation or age of
than their non-core counterparts to express regret following onset. Fifteen FtM patients were categorized as homosexual and
SRS. early-onset, 1 was categorized as homosexual and late-onset, and
Chivers and Bailey (2000) surveyed 39 FtM transsexuals, 1 was categorized as nonhomosexual and late-onset. Two homo-
whom they classified as homosexual or nonhomosexual based sexual, early-onset patients had not yet completed SRS; the
on the participants’ self-reported sexual fantasies, which were nonhomosexual, late-onset patient had decided to forego SRS.
categorized using a Kinsey scale (Kinsey et al., 1948). Homo- All but one patient self-rated the global outcome of the sex reas-
sexual FtM transsexuals (Kinsey 4–6; 62% were Kinsey 6) signment process as positive; the exception was the homosexual,
described their childhood behavior as significantly more gender- late-onset patient, whose self-rated outcome was negative. Cli-
atypical than nonhomosexual FtM transsexuals (Kinsey 0–3); the nicians rated the global outcomes of the 15 homosexual, early-
groups did not differ significantly in their self-described child- onset patients as positive in 7 cases, neutral in 5 cases, and neg-
hood gender identity. Compared with their nonhomosexual coun- ative in 3 cases; they rated the global outcome of the homosexual,
terparts, homosexual FtM transsexuals reported a significantly late-onset patient as negative and that of the nonhomosexual, late-
greater number of sexual partners, greater interest in visual sexual onset patient as positive. The small percentages of nonhomo-
stimuli, and greater sexual versus emotional jealousy. sexual and late-onset patients FtM patients in this study preclude
Herman-Jeglińska et al. (2002) classified FtM transsexuals meaningful statistical analyses.
as primary or secondary, just as they had for MtF transsexu-
als. Although their typology nominally was based on age of
onset, all of the primary FtM transsexuals studied by Herman-
Jeglińska et al. were exclusively homosexual, whereas none of Unambiguity, Ease of Ascertainment, and Reliability
their secondary FtM transsexuals were (albeit most had only of Subtypes in Typologies Based on Sexual Orientation
incidental heterosexual experience). Consequently, the authors’ versus Age of Onset
FtM transsexual typology could equally well be interpreted as
emphasizing sexual orientation. Compared with their secondary Conclusions regarding the unambiguity, ease of ascertainment,
FtM counterparts, primary FtM transsexuals were significantly and reliability of subtypes in typologies based on sexual ori-
less likely to have been married or to have had children, but the entation versus age of onset of GID-related symptoms are sum-
two groups did not differ significantly in age at clinical pre- marized in Table 5.
sentation or in self-rated masculinity or femininity.
As previously noted, Haraldsen et al. (2003) applied their age
of onset-based typology of GID to FtM as well as MtF patients, Typologies Based on Sexual Orientation
but did not describe FtM patients separately, except to observe
that their cognitive performance was not different from that of The DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000)
nontranssexual women. Haraldsen et al. never described any employed a sexual orientation-based typology for GID con-
late-onset FtM patients nor any general characteristics of such sisting of four subtypes, defined in terms of sexual attraction to
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Table 5 Comparison of typologies for gender identity disorder based on sexual orientation versus age of onset
Criterion Typologies based on sexual orientation Typologies based on age of onset of GID-related
symptoms
Is the basis for subtype Yes: Usual categories of sexual orientation (to males, No: There is little agreement about which symptoms or
assignment females, both, or neither) are widely understood and behaviors are most relevant, or about what constitutes
unambiguous? accepted early versus late onset
Can subtypes be easily Yes, via self-report; formal self-report scales are readily Yes, via self-report; but formal self-report scales are not
ascertained? available readily available
Can subtypes be reliably Not always: Self-report can be unreliable in some males Not always: Self-report is often described as unreliable;
ascertained? who claim to be sexually attracted to males; however, however, family members can sometimes confirm age
several objective measures of sexual orientation exist of onset of overt cross-gender behavior
Does the typology facilitate Yes, especially in MtF transsexuals, in whom gynephilia No, especially in late-onset MtF transsexuals, who are
concise, comprehensive or its absence is one of the best predictors of other heterogeneous with respect to many important clinical
clinical description? important clinical features (e.g., cross-gender fetishism features (e.g., sexual orientation, cross-gender
and childhood gender-atypicality) fetishism, and childhood gender-atypicality)
Does the typology offer Yes: Several studies suggest that homosexual orientation Somewhat: One study suggests that earlier onset of gender
prognostic value for is associated with better subjective outcomes following dysphoria may be associated with better outcomes
treatment-related MtF sex reassignment (e.g., fewer regrets and greater following MtF SRS; another suggests that earlier onset
outcomes? satisfaction), but with a lower prevalence of stable may be associated with a greater likelihood of dropping
partnered relationships out of treatment
Does the typology offer Yes: A few studies suggest that homosexual orientation is No: There is little, if any, evidence that age of onset of
predictive value for associated with better psychological functioning in GID-related symptoms is predictive of comorbid
comorbid both MtF and FtM transsexuals psychopathology
psychopathology?
Does the typology facilitate Yes: Typologies based on sexual orientation have directly Very little: Typologies based on age of onset have directly
research and offer facilitated or inspired several informative, interesting, facilitated or inspired few informative, interesting or
heuristic value? and clinically useful research studies clinically useful research studies, partly due to lack of
agreement on definitions of the relevant categories
males, females, both sexes, or neither sex. The subtypes in arousal tends to be category-specific (i.e., consistent with
Blanchard’s (1989a) sexual orientation-based typology were reported or observed sexual interests; Lawrence et al., 2005). In
equivalent: homosexual, heterosexual, bisexual, and anallo- nontranssexual women, objective measures of sexual arousal or
erotic. These subtypes (or at least the first three) appear to be interest are less well correlated with sexual partner preference
widely understood and largely unambiguous to the general (Chivers et al., 2004); whether this might also be true of some or
public (Laumann et al., 1994), as well as to professionals. Sexual most females with GID has not been studied.
attraction is usually ascertained through self-report; several Self-reported sexual orientation is not always reliable in
formal self-report scales for sexual orientation are available males with GID. In a study by Walworth (1997), 6 (12%) of 52
(e.g., Kinsey et al., 1948; Klein, Sepekoff, & Wolf, 1985; see MtF transsexuals admitted having deliberately lied to or misled
also McConaghy, 1998). In addition,‘‘the investigator often has their therapists about their sexual attraction to women; 4 (8%)
the objective evidence of marriage or common-law relation- admitted having done so about their sexual attraction to men. In
ships to take into consideration’’ (Blanchard, 1989a, p. 327) some cases, self-reported attraction to men has been observed
when deciding sexual orientation. In research settings, various to be inconsistent with objective indicators of sexual attraction,
methodologies exist for assessing sexual arousal or interest in such as predominant sexual partnership history (Lawrence, 2005,
response to visual or auditory sexual stimuli involving same-sex 2008a) and neovaginal photoplethysmography (Lawrence et al.,
or opposite-sex persons; these include penile and vaginal pleth- 2005). Moreover, males with GID who have a history of sexual
ysmography (e.g., Barr & Blaszczynski, 1976; Chivers, Rieger, attraction to women sometimes report changes in their sexual
Latty, & Bailey, 2004; Lawrence, Latty, Chivers, & Bailey, orientations following gender transition, resulting in sexual
2005; Rieger, Chivers, & Bailey, 2005), viewing time (e.g., attractions that are supposedly directed primarily or exclusively
Harris, Rice, Quinsey, & Chaplin, 1996; Rullo, Strassberg, & towards men (e.g., Daskalos, 1998; Lawrence, 2005). Such
Israel, 2009), other visual methods (e.g., Jiang, Costello, Fang, reported changes are inconsistent with the longstanding obser-
Huang, & He, 2006; Wright & Adams, 1994), and brain imaging vation that sexual orientation (i.e., direction of sexual attraction)
(e.g., Hu et al., 2008; Paul et al., 2008; Safron et al., 2007). These in males is essentially unchangeable in adulthood (Harry, 1984;
objective measures can serve to confirm or contradict self- Pillard & Bailey, 1995; Swaab, 2007). Freund (1985) summa-
reported sexual orientation in males with GID, in whom sexual rized some possible interpretations of this inconsistency:
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Arch Sex Behav (2010) 39:514–545 531
It is not easy, and often impossible, to decide whether theory, also be used to confirm age of onset of childhood gender-
these patients deliberately try to mislead the examiner, nonconformity. Rieger, Linsenmeier, Gygax, and Bailey (2008)
just appearing as feminine as possible in order to have studied the relationship between self-reported childhood gen-
a better chance of obtaining a recommendation for sex der-nonconformity and childhood gender-nonconformity as
reassignment surgery, or whether their wish to be in the rated by others (based on the content of home videos made
female role in sexual interaction results in fantasies of during participants’ childhoods) in homosexual and hetero-
sexual intercourse as a female with a male and that this sexual men and women. For homosexual men, the correlation
makes them prefer the male as a sexual partner, in spite of between self-reported and other-rated childhood gender-non-
not being attracted toward male but toward female body conformity was high (.60) but far from perfect; correlations
shapes. (pp. 265–266) were substantially lower for heterosexual men and for women.
In summary, clinicians and researchers would probably find it
Typologies Based on Age of Onset difficult to confirm or contradict self-reported age of onset of
cross-gender feelings and behaviors in transsexual patients.
For transsexual typologies based on age of onset, the most Investigators have observed that transsexuals’ self-reports
appropriate GID-related symptom by which to define onset concerning the early onset of gender dysphoria, cross-gender
and the most appropriate dividing point for distinguishing identity, or cross-gender behavior are often unreliable.
early- from late-onset subtypes are not self-evident. As noted Lukianowicz (1959), for example, concluded that male gender
previously, investigators have offered differing opinions about patients’ self-reports concerning the early onset of their cross-
exactly which feelings or behaviors, if they occurred early in gender feelings were often inaccurate:
life, were typologically significant: Some have emphasized gen-
A wishful falsification of memory takes place, the patients
der dysphoria (or unremitting gender dysphoria), others cross-
begin to recall and misinterpret various insignificant inci-
gender identity, and still others gender-atypical behavior. Inves-
dents in their childhood, till they finally firmly believe that
tigators have also differed about how best to distinguish between
‘‘ever since I can remember, I always wanted to be a
early versus late onset. For some,‘‘early’’meant early childhood;
woman.’’ (The incessant progress of these emotionally
others considered any time before puberty to be‘‘early.’’In adult
overvalued ideas resembles the relentless development of
patients, age of onset, however defined, is usually ascertained
delusions in paranoia.) (p. 51)
based on self-report. Some items in the Dutch-language Bio-
graphical Questionnaire for Transsexuals (Doorn et al., 1994; Bancroft (1972) similarly believed that a possible complicating
Smith et al., 2005a, b) concern age of onset of cross-gender factor in understanding the development of MtF transsexualism
feelings and behaviors, but this scale is unpublished. One item in was that
Blanchard’s (1993b) Pure Gender Dysphoria Scale for males
asks about the onset of gender dysphoria before age 12. I have transexuals [sic] distort their past histories to fit into their
been unable to locate other published self-report inventories that transexual identity and are therefore more likely to report
include items related to age of onset of GID-related symptoms. early transexual urges to support the idea that they are
In principle, parents or other family members could confirm basically female….[One patient] when first seen reported
or contradict the self-reported age of onset of cross-gender feel- his transexual feelings to be of recent origin; nine months
ings and behaviors in transsexual patients. Wålinder (1967) later he was reporting them as starting much earlier in his
attempted to confirm the age of onset of cross-gender behaviors life. (p. 62)
in his patients by interviewing their parents, but he was suc- Fisk (1974b), too, noted the tendency of candidates for sex
cessful in obtaining information in only 17 (40%) of 43 cases; in reassignment to deliberately or inadvertently misrepresent their
2 of the 17 cases, the parents denied noticing anything unusual. histories to make them consistent with accepted ideas about
In a report relevant to the accuracy of parental confirmation of classical (i.e., early-onset) transsexualism:
gender-atypicality, Bailey, Nothnagel, and Wolfe (1995) exam-
ined the correlation between self- and maternal reports of child- Slowly, there appeared instances in which the seemingly
hood feminine interests and feminine gender identity in a group very pat histories revealed inconsistencies, downright
of homosexual men. They found that 89% of the mothers of their fabrications and blatant distortions….The element of
participants were willing to complete questionnaires, and that conscious fabrication or manipulation seemed quite sec-
self- and maternal reports were moderately correlated for both ondary to the phenomenon of retrospectively‘‘amending’’
feminine interests and feminine gender identity in childhood one’s subjective history. Here, the patient quite subtly
(.47 and .43, respectively), but were far from identical. It is not alters, shades, rationalizes, denies, represses, forgets, etc.,
clear whether these results might be generalizable to patients in a compelling rush to embrace the diagnosis of trans-
with GID. Video recordings made during childhood could, in sexualism. (pp. 8–9)
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532 Arch Sex Behav (2010) 39:514–545
Sørensen and Hertoft (1980) likewise observed that MtF trans- (APA, 2000) discussed the desirable characteristics of typologies
sexuals typically displayed‘‘memory distortion with exclusion used for this purpose:
of earlier masculine traits’’(p. 139). Levine and Lothstein (1981)
Naming of categories is the traditional method of orga-
cautioned that females with gender dysphoria, too, sometimes
nizing and transmitting information in everyday life and
did not accurately describe the development of their cross-
has been the fundamental approach used in all systems of
gender feelings: ‘‘All females requesting SRS describe persis-
medical diagnosis. A categorical approach to classifica-
tent masculine fantasies. Like the males, however, they may be
tion works best when all members of a diagnostic class are
guilty of consciously or unconsciously distorting their develop-
homogeneous, when there are clear boundaries between
mental histories.’’ (p. 96). Walworth (1997) reported that three
classes, and when the different classes are mutually exclu-
of the five most common subjects about which MtF transsexuals
sive. (p. xxxi)
admitted having lied to or misled their therapists included‘‘pre-
ferring girls’ games and toys as a child[,] childhood wishes to Homogeneity within subtypes is an especially important
have been born a girl[, and] identifying with female characters contributor to concise, comprehensive clinical description; it
as a child’’(p. 359). will be addressed specifically in the discussion that follows.
The most recent edition of the Standards of Care for Gender
Identity Disorders of the Harry Benjamin International Gender Typologies Based on Sexual Orientation
Dysphoria Association (Meyer et al., 2001) proposed that pri-
mary (‘‘true’’) transsexualism in males was a rare phenomenon Typologies based on sexual orientation offer substantial descrip-
and that many supposed cases of primary MtF transsexualism tive value in MtF transsexualism. As the data in Table 1 indicate,
were attributable to patients who had falsified their histories: most investigators who have proposed such typologies have
observed that homosexual MtF transsexuals tend to differ from
During the 1960s and 1970s, clinicians used the term true
nonhomosexual MtF transsexuals in other clinically important
transsexual….True transsexuals were thought to have: 1)
ways. Compared with their nonhomosexual counterparts, exclu-
cross-gender identifications that were consistently expres-
sively homosexual MtF transsexuals are more likely to report
sed behaviorally in childhood, adolescence, and adulthood;
overt cross-gender behavior during childhood (Blanchard, 1988;
2) minimal or no sexual arousal to cross-dressing; and 3) no
Money & Gaskin, 1970–1971; Whitam, 1987, 1997), but are less
heterosexual interest, relative to their anatomic sex….
likely to report cross-gender fetishism (Bentler, 1976; Blanchard,
Belief in the true transsexual concept for males dissipated
1985, 1989b; Lawrence, 2005; Money & Gaskin, 1970–1971;
when it was realized that such patients were rarely encoun-
Smith et al., 2005b; Whitam, 1987, 1997). Homosexual MtF
tered, and that some of the original true transsexuals had
transsexuals also seek treatment at younger ages than their non-
falsified their histories to make their stories match the
homosexual counterparts (Blanchard, 1988; Smith et al., 2005b),
earliest theories about the disorder. (p. 9)
and their physical appearance is more congruent with their gender
Although the statement by Meyer et al. notes the unreliability of identity (Smith et al., 2005b). In a study of 422 gender-dysphoric
reports of consistent, life-long cross-gender identification and males, Blanchard, Dickey, and Jones (1995) observed that homo-
expression (the key features of most typologies based on age of sexual patients were significantly shorter, lighter, and lighter in
onset), it also suggests that reports of exclusive homosexual proportion to their height than their nonhomosexual counterparts;
interest (the key feature of typologies based on sexual orien- although Smith et al. (2005b) were unable to confirm these find-
tation) are often misrepresented. ings in a study of 113 MtF transsexuals, their study was under-
In a recent review article, Cohen-Kettenis and Pfäfflin (2009) powered to detect any but large effect sizes (Cohen, 1988). Homo-
summarized the situation by stating without qualification that sexual MtF transsexuals appear to be so strikingly different from
‘‘retrospective data of [transsexual] adults regarding the date of their nonhomosexual counterparts that the two subtypes appear
onset of their feelings of being different are not reliable.’’ to represent completely different clinical spectra (Whitam,
1987) and plausibly reflect entirely different etiologies (Freund,
1985; Smith et al., 2005b).
Descriptive Value of Typologies Based on Sexual MtF transsexuals in most Western countries are predominantly
Orientation versus Age of Onset nonhomosexual (Lawrence, 2008c), so it is especially impor-
tant to consider the extent to which nonhomosexual MtF trans-
Conclusions regarding the descriptive value of transsexual typol- sexuals constitute a homogeneous group. In most respects, this
ogies based on sexual orientation and age of onset of GID-related appears to be the case: Nonhomosexual MtF transsexuals
symptoms are summarized in Table 5. One of the principal rea- who are attracted to women, to women and men, and to nei-
sons for creating typologies and classification systems for mental ther women nor men do not differ significantly with respect
disorders is to facilitate concise, comprehensive clinical descrip- to cross-gender fetishism (Blanchard, 1985), childhood
tion by and for mental health professionals. The DSM-IV-TR cross-gender behavior (Blanchard, 1988), age of clinical
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Arch Sex Behav (2010) 39:514–545 533
presentation (Blanchard, 1988), or autogynephilic sexual cross-dressing or cross-gender fantasies. The authors used mea-
arousal (Blanchard, 1989b; see also Lawrence, 2005). In a few sures of androphilia and gynephilia developed by Blanchard
respects, however, the three nonhomosexual MtF groups do (1985), which were nominally independent of each other;
differ in important ways: Whereas autogynephilia is charac- consequently, respondents could report high levels of both an-
teristic of all three subtypes (Blanchard, 1989b; Lawrence, drophilia and gynephilia (i.e., bisexual attraction) or low levels
2005), arousal to the thought of being admired as a woman by of both (i.e., analloeroticism). Johnson and Hunt found that
another person (autogynephilic interpersonal fantasy) is espe- androphilia was not significantly associated with any other
cially characteristic of bisexual MtF transsexuals (Blanchard, typological variable but that gynephilia was significantly and
1989b), whereas analloeroticism, not surprisingly, is especially positively associated with cross-gender fetishism (r = .36) and
characteristic of MtF transsexuals who are attracted to neither significantly and negatively associated with feminine gender
women nor men (Blanchard, 1989b). MtF transsexuals belong- identity in childhood (r = -.32); note that the last finding repli-
ing to different nonhomosexual subtypes also differ signifi- cates an observation by Freund et al. (1982). Johnson and Hunt
cantly in the number of sexual partners and number of episodes of also found that age of onset was significantly and negatively asso-
sexual activity they report following SRS (Lawrence, 2005). ciated with feminine gender identity in childhood (r = -.35) but
Blanchard (1989a) proposed that, in research studies involving with no other typological variable. These results suggested that,
more than a few MtF participants, researchers should specify among the five typological variables studied, gynephilia and
whether nonhomosexual MtF transsexuals were heterosexual, feminine gender identity in childhood conveyed the most useful
bisexual, or analloerotic; this seems advisable, given that this descriptive information, because each was significantly associ-
subcategorization of the nonhomosexual group provides addi- ated with the other and each was also significantly associated with
tional descriptive value. one other typological variable. Age of onset and cross-gender
Two important studies, conducted by Freund et al. (1982) and fetishism appeared to be less useful descriptively, and androphilia
Johnson and Hunt (1990), addressed the comparative descriptive was least useful, presumably because it was reported by both
value of a number of features associated with MtF transsexual- exclusively homosexual and ostensibly bisexual (i.e., pseudobi-
ism; both studies found sexual orientation, and gynephilia spe- sexual; Blanchard, 1989b) persons, who might otherwise have
cifically, to be an important, and arguably the most important, few traits in common.
descriptive feature. As previously discussed, Freund et al. studied The study by Johansson et al. (2009), which presented data
136 male patients with varying degrees of cross-gender identity, about sexual orientation and age of onset of the wish to become
most of whom were transsexuals or ‘‘borderline transsexuals.’’ the opposite sex in 25 MtF transsexuals, provided additional
They examined the extent to which an overall measure of cross- evidence that sexual orientation and age of onset are only
gender identity was associated with eight variables that putatively modestly associated in such patients. Among 13 homosexual
contributed to it: androphilia, gynephilia, childhood femininity, MtF patients, 7 were early-onset and 6 were late-onset; among
fetishism, heterosexual experience, analloeroticism, masochism, 12 nonhomosexual MtF patients, 4 were early-onset and 8 were
and sadism. Masochism and sadism were included because of late-onset. The resulting four-fold point correlation coefficient
‘‘clinical experience that strong masochism in males often occurs (/ or w) = .21; this represents a small effect size (Cohen, 1988).
together with transvestism’’ (Freund et al., p. 51). The authors’ Less information is available concerning the descriptive value
overall measure of cross-gender identity was empirically derived of sexual orientation in FtM transsexuals. Limited evidence sug-
from principal component analysis of patient data for the eight gests that homosexual FtM transsexuals display greater child-
putative contributing variables. The first (largest) factor derived hood masculinity, and sexual attitudes that are more male-typical,
from the analysis, which Freund et al. called type of cross-gender than their nonhomosexual counterparts (Chivers & Bailey, 2000).
identity, accounted for roughly 47% of the total variance, with all Homosexual and nonhomosexual FtM patients have not been
other factors being much smaller. The variable with the highest shown to differ, however, in childhood gender identity (Chivers
loading on type of cross-gender identity was gynephilia (loading & Bailey, 2000) or in age of clinical presentation, history of mar-
.91), followed by childhood femininity (-.79), fetishism (.79), riage, or congruence of physical appearance with gender identity
and androphilia (-.78); loadings for the other variables were (Smith et al., 2005b).
much lower. Freund et al. concluded that there were two main
types of cross-gender identity: one associated with gynephilia and Typologies Based on Age of Onset
fetishism, the other associated with childhood femininity and
androphilia. Typologies based on age of onset of GID-related symptoms also
Johnson and Hunt (1990) studied 25 MtF transsexuals in the offer descriptive value in MtF transsexualism, but arguably
process of gender transition, examining the interrelationships less than typologies based on sexual orientation. As the data
between five variables they believed to be related to transsexual in Table 2 indicate, many investigators have observed that early-
typology: androphilia, gynephilia, cross-gender fetishism, fem- onset MtF transsexuals tend to differ from late-onset MtF trans-
inine gender identity in childhood, and age of onset of either sexuals in other clinically important ways. For example, com-
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pared with their late-onset counterparts, early-onset MtF trans- FtM transsexuals have been described as homosexual, but so
sexuals usually display more cross-gender behavior during have most late-onset FtM transsexuals (Dolan, 1987; Landén
childhood (Docter, 1988; Dolan, 1987; Doorn et al., 1994; Laub et al., 1998; Levine & Lothstein, 1981; Seil, 2004).
& Fisk, 1974; Levine & Lothstein, 1981; Lundström et al., 1984;
Seil, 1996, 2004; Stoller, 1979, 1980; but see Person & Ovesey,
1974a, b) and less cross-gender fetishism (Burns et al., 1990; Prognostic Value of Typologies Based on Sexual
Docter, 1988; Dolan, 1987; Fisk, 1974a, b; Levine & Lothstein, Orientation versus Age of Onset for
1981; Lundström et al., 1984; Person & Ovesey, 1974a, b; Seil, Treatment-Related Outcomes
1996; Stoller, 1979, 1980; but see Doorn et al., 1994, and
Johnson & Hunt, 1990). Clinicians who treat patients with GID have historically been
In most reports, late-onset MtF transsexuals have been interested in patient characteristics that influence response to
described as greatly outnumbering their early-onset counter- treatment. Treatment-related outcomes include satisfaction
parts (Dolan, 1987; Levine & Lothstein, 1981; Lundström et al., or regret, continuation versus discontinuation of treatment,
1984; Seil, 2004; Stoller, 1980; but see Doorn et al., 1994, and and psychological and social functioning following sex reas-
Johansson et al., 2009). Consequently, it is important to consider signment. Conclusions regarding the comparative value of
the extent to which late-onset MtF transsexuals constitute a rela- transsexual typologies based on sexual orientation versus age
tively homogeneous group. Investigators have routinely found, of onset of GID-related symptoms for predicting treatment-
however, that late-onset MtF transsexuals are quite heteroge- related outcomes are summarized in Table 5.
neous. Person and Ovesey (1974a, b), Laub and Fisk (1974), Fisk (1974a) observed that both classic (early-onset, homo-
Stoller (1979, 1980), Levine and Lothstein (1981), Lundström sexual) and effeminate homosexual (late-onset, homosexual)
et al. (1984), Dolan (1987), and Docter (1988) all observed that gender dysphoric MtF patients showed significant improve-
late-onset MtF transsexuals comprised at least two disparate ments in social, psychological, economic, and sexual adjust-
groups: extremely effeminate men with no history of cross- ment after sex reassignment. For transvestite (late-onset, nonho-
fetishism who were exclusively homosexual and reasonably mosexual) gender-dysphoric MtF patients, sexual adjustment
masculine men with a history of cross-gender fetishism who improved significantly after sex reassignment (Fisk, 1974a),
were primarily heterosexual. As noted earlier, the extreme while social and psychological adjustment became no worse
diversity of clinical presentations among late-onset or second- (Laub & Fisk, 1974). Taken together, these results suggest that,
ary MtF transsexuals led Stoller (1980) to declare that the cat- in this study, sexual orientation showed a stronger association
egory constituted little more than a‘‘wastebasket’’(p. 1700). with treatment-related outcomes than did age of onset.
As previously discussed, Johnson and Hunt (1990) found that, Bentler (1976) noted that some questionnaire data he
in MtF transsexuals, age of onset of cross-dressing or cross- obtained were‘‘suggestive of a relatively higher level of strain’’
gender fantasies was significantly and negatively associated with (p. 575) for homosexual and asexual MtF transsexuals than for
feminine gender identity in childhood but was not significantly their heterosexual counterparts. Moreover, one quarter of the
associated with any other variable of interest (androphilia, gyne- homosexual MtF participants reported that‘‘life as a woman was
philia, or cross-gender fetishism). Age of onset was somewhat not up to expectations’’ (p. 576), whereas no heterosexual or
less valuable descriptively than gynephilia, which was also sig- asexual MtF participants reported this. Bentler concluded that
nificantly and negatively associated with feminine gender iden- there was some meaningful association between sexual orien-
tity in childhood and which was, in addition, significantly and tation and quality of outcomes in MtF sex reassignment.
positively associated with cross-gender fetishism. As previously Wålinder, Lundström, and Thuwe (1978) examined factors
noted, data from Johansson et al. (2009) demonstrated that, in associated with satisfaction or regret following SRS in a group
MtF transsexuals, age of onset of the wish to become the opposite of 14 MtF transsexuals, 5 (36%) of whom were regretful.
sex displayed only a modest association with sexual orien- Among the regretful patients, 4 of 5 reported heterosexual expe-
tation. The study by Herman-Jeglińska et al. (2002), in contrast, rience, whereas among the nonregretful patients, only 2 of 9
could be interpreted as suggesting that age of onset was strongly reported heterosexual experience (p = .06, one-tailed; p = .09,
predictive of sexual orientation, in that all the primary MtF two-tailed). Despite this finding of only trend-level significance
patients studied were exclusively homosexual, whereas none of the at a conventional alpha level, the authors concluded that ‘‘het-
secondary MtF patients were; but this ‘‘perfect’’ correlation evi- erosexual experience [was] present significantly more often in
dently reflected Herman-Jeglińska et al.’s use of nonhomosexual those transsexuals who regretted the measures taken’’(p. 19).
orientation (and cross-gender fetishism, with which it is commonly Lindemalm, Korlin, and Uddenberg (1987) examined fac-
associated), rather than age of onset per se, as the principal basis for tors predictive of positive outcomes of SRS in 13 MtF trans-
categorizing patients as secondary MtF transsexuals. sexual patients. In contrast to the findings of some other studies,
Little information is available concerning the descriptive the authors found that both heterosexual experience and bisex-
value of age of onset in FtM transsexuals. Nearly all early-onset ual experience were associated with better, not worse, sexual
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adjustment after SRS. Early onset of gender-atypicality (playing achieved ‘‘good’’ outcomes and those who achieved only ‘‘sat-
with girls during childhood, feminine behavior during child- isfactory’’outcomes.
hood, cross-dressing before age 10) was not associated with Kuiper and Cohen-Kettenis (1998) described 10 transsexual
better outcomes for psychosocial adjustment, sexual adjust- patients (9 MtF, 1 FtM) who expressed regret following SRS or
ment, or nonrepentence. reverted to living in their original gender role. Based on the case
Kockott and Fahrner (1988) commented on the prevalence summaries provided, all but 1 of the MtF patients were non-
and stability of partnered relationships among 37 MtF trans- homosexual (heterosexual, bisexual, or analloerotic), as was the
sexuals who had completed SRS. Of the 10 MtF transsexuals FtM patient (bisexual). Only the homosexual MtF patient and
who reported such relationships, 4 were partnered with women the FtM patient displayed gender-atypical behavior during
and 6 with men. On the basis of qualitative data, Kockott and childhood. Five of the patients, including the FtM patient,
Fahrner concluded that ‘‘partnerships between male-to-female reported an onset of gender dysphoria at age 8 or earlier, whereas
transsexuals and female partners seem to last longer than part- the other 5 patients reported an onset of gender dysphoria at age
nerships with male partners’’(p. 544). 12 or later. Two of the MtF patients cross-dressed incidentally
Blanchard, Steiner, Clemmensen, and Dickey (1989) before puberty; the other patients began cross-dressing only
reported that, in a group of 50 MtF transsexuals who had after puberty. Two of the MtF patients had a history of sexual
completed SRS, 4 (29%) of 14 nonhomosexual MtF patients arousal with cross-dressing. The authors concluded that caution
either regretted having undergone SRS or were not certain they was indicated in offering sex reassignment to patients with‘‘late
would undergo SRS again if they had it to do over. Of 36 onset of the gender conflict, fetishistic cross-dressing, psycho-
homosexual MtF transsexuals, none were regretful. Despite logical instability and/or social isolation’’ (Discussion section,
the small sample sizes, the difference in prevalence of regret } 5). It appears, however, that the most commonly shared fea-
between the homosexual and nonhomosexual groups was sta- tures among the regretful patients were nonhomosexual orien-
tistically significant. tation (9 of 10 patients) and late onset of overt cross-gender
In a study previously discussed, Johnson and Hunt (1990) expression (8 of 10 patients), although Kuiper and Cohen-
examined associations between five predictor variables related Kettenis did not emphasize either of these features. It is also
to transsexual typology—androphilia, gynephilia, cross-gender notable that half of the regretful patients reported an onset of
fetishism, feminine gender identity in childhood, and age of gender dysphoria before age 8.
onset of cross-dressing or cross-gender fantasies—and three Landén et al. (1998) investigated regret following SRS in a
variables related to outcomes of gender transition in 25 MtF mixed group of MtF (n = 124) and FtM (n = 94) transsexuals.
transsexuals. The outcome variables were social gender reori- The authors distinguished between core and non-core transsex-
entation (consistency of self-presentation as a female and pos- uals; as noted earlier, the key features of their definition of core
session of gender-appropriate identity documents), physical transsexualism were unremitting (and by implication, early-
gender reorientation (use of feminizing hormones, having onset) gender dysphoria and aversion to biological sex charac-
undergone vaginoplasty), and work adjustment (ability to be teristics. Landén et al. found that non-core transsexuals were
self-supporting through employment). Androphilia was signifi- more likely to express regret following SRS than core transsex-
cantly associated with better social gender reorientation, whereas uals. Age of onset was not significantly associated with regret,
gynephilia was significantly associated with better work adjust- however, suggesting that other features of the core/non-core
ment. Age of onset of cross-dressing or cross-gender fantasies typology explained the observed difference in regret between the
was not significantly associated with any of the outcome variables groups. Surprisingly,therewas anonsignificant trend (p = .08)for
examined. ‘‘conditions bordering on homosexuality’’(a subcategory of non-
Pfäfflin (1992) described the outcomes of SRS in 196 MtF core transsexualism) to be associated with a higher prevalence of
transsexual patients, 3 of whom expressed regret. All 3 regretful regret, although neither homosexual nor heterosexual experience
patients were evidently nonhomosexual, reporting no sexual per se was significantly associated with regret.
experience with males but long-term partnerships with females. Muirhead-Allwood, Royle, and Young (1999) examined
One regretful patient began cross-dressing before age 10, and regret following SRS in 140 MtF transsexual patients, 9 (6%) of
the other 2 began at puberty. Pfäfflin concluded that nonhomo- whom expressed some postoperative regret. Eight (89%) of the 9
sexual orientation was a possible risk factor for regret following regretful patients reported a nonhomosexual orientation before
MtF sex reassignment but offered no conclusions regarding age SRS. Although the authors emphasized the preponderance of
of onset of cross-gender expression as a possible risk factor. nonhomosexual orientation among regretful participants, 114
Tsoi (1993) examined outcomes of SRS in 45 MtF and 36 (86%) of the 133 patients for whom preoperative sexual orien-
FtM transsexual patients, all of whom were exclusively homo- tation data were available were nonhomosexual, so the relation-
sexual in orientation. Among the MtF patients, age of onset of ship between sexual orientation and regret in this study was not
gender dysphoria was not significantly different in patients who statistically significant.
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Lewins (2002) studied the prevalence of stable partnered symptoms during childhood were more likely to drop out of
relationships in self-identified MtF transsexuals, not all of treatment prematurely.
whom had completed SRS. MtF transsexuals who identified as Olsson and Möller (2006) described the long-term follow-up
lesbian (i.e., heterosexual relative to birth sex) were signifi- of a nonhomosexual MtF transsexual who expressed regret after
cantly more likely to be in a stable relationship than MtF transsex reassignment. Although reports of single cases obviously
sexuals who identified as heterosexual (i.e., homosexual relative must be interpreted cautiously, regret following sex reassign-
to birth sex). ment is rare enough that such cases are worth noting. The patient
Lawrence (2003) investigated the relationship between was categorized as nonhomosexual on the basis of self-reported
variables related to transsexual typology and subjective out- sexual attraction to women and successful sexual relationships
comes of SRS in 232 MtF transsexuals. The typological vari- with women. The patient’s childhood medical records described
ables of greatest interest were age at first wish to change sex or be several characteristics usually associated with early-onset GID:
the other sex, childhood femininity in the participant’s opinion, As a preschool child, the patient‘‘preferred to play with girls and
childhood femininity in others’ probable opinion, sexual attrac- with dolls. He also liked to dress as a girl’’(p. 502).
tion to males versus females, sexual experience with males Weyers et al. (2009) investigated mental and physical
versus females, and frequency of autogynephilic sexual arousal. health in 50 MtF transsexual patients who had completed
The three outcome variables were absence of regret, happiness SRS. They categorized patients as homosexual, heterosex-
with surgical result, and improvement in quality of life with ual, bisexual, or not sexually interested (asexual), but refer-
SRS. Of 30 correlations examined, only 5 were statistically enced the first two categories to gender identity, rather than
significant: Younger age at first wish to change sex or be the birth sex. In contrast to some previous reports, the authors
other sex and greater childhood femininity in the participant’s observed that androphilic MtF transsexuals were as likely to
opinion were significantly associated with absence of regret; be involved in a current relationship (not necessarily a stable
greater childhood femininity in the participant’s opinion and in or long-term one) as their gynephilic counterparts. They also
others’ probable opinion were significantly associated with found that androphilic MtF transsexuals obtained higher
greater improvement in quality of life; and lower frequency of scores on an index of sexual functioning.
autogynephilic arousal was significantly associated with greater
improvement in quality of life. Measures of sexual orientation
were not significantly associated with any outcome variable. Predictive Value of Typologies Based on Sexual
Because this study was exploratory, statistical results were not Orientation versus Age of Onset for Comorbid
corrected for multiple comparisons; moreover, participants’ Psychopathology
responses displayed limited ranges for all outcome variables
(i.e., most participants rated all outcomes very positively). Con- Most diagnoses in the DSM, including GID, are accompanied
sequently, these results should be interpreted cautiously. by discussions of comorbid psychopathology. The description
Lawrence (2005) examined the association between sexual of GID in DSM-IV-TR (APA, 2000) also mentions that one
orientation and prevalence of stable partnered relationships in sexual orientation-based subtype is associated with comorbid
232 MtF transsexual patients who had completed SRS. Patients psychopathology (i.e., that men with GID who are attracted to
who reported at least one female sexual partner but no male neither sex often display schizoid traits). Accordingly, it may be
sexual partners following SRS were significantly more likely to useful to consider the comparative value of transsexual typol-
be in a stable partnered relationship at the time of the survey than ogies based on sexual orientation versus age of onset of GID-
patients who reported at least one male sexual partner but no related symptoms for predicting comorbid psychopathology.
female sexual partners after SRS. Patients who reported any Only a few studies have addressed this topic; the relevant
female sexual partners following SRS (i.e., behaviorally het- findings are summarized in Table 5.
erosexual or bisexual patients) were more likely to have been in In a study previously discussed, Johnson and Hunt (1990)
a stable partnered relationship at some time following SRS than examined the associations between five variables related to
patients who reported at least one male sexual partner but no transsexual typology (androphilia, gynephilia, cross-gender
female sexual partners after SRS. fetishism, feminine gender identity in childhood, and age of
Smith et al. (2005a) reported outcomes of sex reassignment onset of cross-dressing or cross-gender fantasies) and three
in 220 MtF and 105 FtM applicants. They found that homo- different measures of psychological disturbance (social intro-
sexual transsexuals (MtF and FtM groups combined) experi- version, depression, and tension and worry). They found no
enced less regret, both during treatment and following sex significant association between any typological variable and
reassignment, than their nonhomosexual counterparts and also any of the psychological outcome variables.
experienced better overall postoperative functioning. Surpris- Hartmann, Becker, and Rueffer-Hesse (1997) conducted
ingly, Smith et al. found that applicants who reported more GID psychological testing in 20 MtF transsexuals, 10 of whom were
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homosexual (androphilic) and 10 whom were nonhomosexual etiological or developmental theories associated with that
(gynephilic). They observed that nonhomosexual patients typology; this point of view informs the analysis that follow. It is
reported more neurotic symptoms, based on scores on the Ger- important to note, however, that the DSM is an atheoretical
man short form of the Minnesota Multiphasic Personality Inven- classification system; consequently, adoption of a particular
tory (MMPI): typology for GID does not necessarily imply endorsement of the
theories associated with that typology, regardless of the value of
The scores of the gynephilic patients are clearly higher
such theories in facilitating research.
for the so-called‘‘neurotic trias’’[sic] of Hypochondria,
Perhaps the best evidence of the value of a typology in facil-
Depression[,] and Hysteria, the most valid scales of the
itating research is the frequency with which it is actually utilized
German version of the MMPI. This suggests that the
in clinical and laboratory research studies. As the earlier dis-
gynephilic patients of our sample have more neurotic
cussions concerning prediction of treatment-related outcomes
symptoms, especially of the somatization and psycho-
and comorbid psychopathology demonstrated, several clinical
somatic type. (Results section, } 2)
studies have used transsexual typologies based on sexual ori-
Hartmann et al. did not, however, provide any statistical entation to categorize participants, and many of these studies
analyses of the observed differences. have found significant associations between sexual orientation-
Seil (2004) reported that, in his practice, the prevalence of drug based subtypes and other variables of interest. Fewer clinical
and alcohol abuse, and other secondary diagnoses as well, did not studies have used transsexual typologies based on age of onset
differ significantly between primary (ego-syntonic, early-onset) of GID-related symptoms to categorize participants, and few of
and secondary (ego-dystonic, late-onset) MtF transsexuals or these studies have found significant associations between age of
between primary and secondary FtM transsexuals. onset and other variables of interest.
Smith et al. (2005a) found that homosexual transsexuals Typologies based on sexual orientation also have been
(MtF and FtM patients combined) displayed better psycholog- widely utilized in laboratory research studies, particularly those
ical functioning after sex reassignment than their nonhomo- investigating neuroanatomical or neurophysiological features
sexual counterparts, based on scores on the Dutch version of the associated with GID. Typologies based on age of onset of GID-
Symptom Check List (SCL-90; Derogatis, Lipman, & Covi, related symptoms sometimes have been considered in such
1973). Smith et al. (2005b) likewise reported that homosexual studies as well, but generally have received less attention, espe-
FtM transsexuals reported significantly fewer psychological cially in recent years. A few examples will illustrate these
problems than their nonhomosexual counterparts, again based points. Two influential postmortem studies of hypothalamic (or
on scores on the Dutch SCL-90. limbic) nuclei in the brains of MtF transsexuals (Kruijver et al.,
In a study involving 35 MtF and 27 FtM transsexuals who 2000; Zhou, Hofman, Gooren, & Swaab, 1995), conducted dur-
had undergone SRS, De Cuypere et al. (2006) found that, for ing the previous decade, categorized participants on the basis of
MtF and FtM patients combined, homosexual orientation both sexual orientation and age of onset of gender dysphoria and
was associated with lower psychiatric comorbidity, as indi- devoted roughly equal attention to both typologies in their dis-
cated by scores on the Dutch SCL-90 (Derogatis et al., 1973). cussion sections. A more recent study from the same institution,
When MtF transsexuals were evaluated separately, however, involving many of the same patients (Garcia-Falgueras &
no significant association between sexual orientation and Swaab, 2008), again categorized patients on the basis of both
psychiatric comorbidity was found. sexual orientation and age of onset of gender dysphoria; but only
sexual orientation figured prominently in the discussion. It is
also noteworthy that Garcia-Falgueras and Swaab explicitly
Ability of Typologies Based on Sexual Orientation versus adopted the sexual orientation-based typology proposed by
Age of Onset to Facilitate Research and Provide Heuristic Blanchard (1989a), categorizing patients as homosexual or
Value nonhomosexual relative to birth sex. Three recent brain imaging
studies involving MtF transsexuals and nontranssexual men and
A stated goal of the DSM classification system is to ‘‘facilitate women (Berglund, Lindström, Dhejne-Helmy, & Savic, 2008;
research’’(APA, 2000, p. xxiii). Accordingly, it is appropriate to Gizewski et al., 2008; Luders et al., 2009), in contrast, devoted
compare the ability of transsexual typologies based on sexual little attention to age of onset of GID-related symptoms but
orientation versus age of onset of GID-related symptoms to considerable attention to sexual orientation. For methodological
contribute to this goal; the results of this comparison are sum- reasons, Berglund et al. included only nonhomosexual MtF
marized in Table 5. One important way in which a typology transsexuals in their study; the authors further subdivided their
could facilitate research would be by offering heuristic value: participants into heterosexual and asexual subtypes, as proposed
that is, by inspiring or enabling investigators to conduct infor- by Blanchard (1989a), and discussed their findings in relation
mative, interesting, and useful research studies. Arguably, part to these subtypes. Although Berglund et al. reported the age
of the ability of a typology to facilitate research derives from the of onset of gender dysphoria in their participants, they never
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538 Arch Sex Behav (2010) 39:514–545
addressed this typological feature in their discussion. Gizewski coexistence and competition of autogynephilia and various
et al. described the sexual orientation of their MtF participants forms of heterosexual attraction led, in turn, to the concept of
and discussed how sexual orientation might have influenced erotic target location errors (Blanchard, 1991; Freund &
participants’ responses to stimulus materials; they did not Blanchard, 1993; see also Lawrence, 2009b): the theory that
describe the age of onset of participants’ GID-related symp- autogynephilia and similar erotic interests represented devel-
toms. Luders et al. also described the sexual orientation of their opmental errors in locating erotic targets in the environment.
MtF participants but did not mention age of onset of GID-related The concept of erotic target location errors inspired still further
symptoms. Luders et al. did not analyze homosexual and non- investigation concerning possible analogues of autogynephilia
homosexual participants separately, but they acknowledged that such as apotemnophilia (paraphilic interest in undergoing limb
this was a limitation of their study; after referencing Blanchard’s amputation; Lawrence, 2006) and autoandrophilia (sexual
(1989a, b) typology, they proposed that‘‘future studies that take arousal to the thought or image of oneself as a male; Dickey &
into consideration sexual orientation [in MtF transsexuals] will Stephens, 1995) as it manifests in androphilic men (Lawrence,
not only further reveal the underlying determinants of gender 2009a). These developments, which have advanced our under-
identity in general, but also possibly advance our understanding standing of both MtF transsexualism and the paraphilias, were
of different transsexual subtypes’’(p. 907). outgrowths of Blanchard’s original adoption of a sexual orien-
This greater emphasis on typologies based on sexual orientation-based classification system for MtF transsexualism.
tation is not unexpected: Because sexual orientation is a more Several early studies demonstrated that homosexual non-
unambiguous and more reliable basis for categorization than transsexual men have a significantly later birth order than
age of onset of GID-related symptoms, it is not surprising that nonhomosexual nontranssexual men (Hare & Moran, 1979;
clinical and laboratory researchers have utilized it more often. Slater, 1962), as well as a higher proportion of male siblings
Moreover, because sexual orientation appears to carry greater (Kallmann, 1952). Working from a sexual orientation-based
descriptive value than age of onset of GID-related symptoms in typology for MtF transsexualism, Blanchard and Sheridan (1992)
MtF transsexualism, and perhaps in FtM transsexualism as well, demonstrated that homosexual gender dysphoric men had a
it is not surprising that sexual orientation would display stronger significantly later birth order and a higher proportion of male
associations with other variables of interest. siblings than the nonhomosexual gender dysphoric men. These
It may be useful to consider some additional illustrations of results provided an important replication of earlier findings
the value of typologies based on sexual orientation versus age of concerning birth order and sibling sex ratio in homosexual men,
onset of GID-related symptoms in facilitating research, in areas one that would not have been possible if the authors had not
in other than the investigation of treatment-related outcomes, utilized a such a typology. The results also demonstrated the
comorbid psychopathology, and possible neuroanatomical and heuristic value of this sexual orientation-based typology, lead-
neurophysiological correlates of GID. ing Cohen-Kettenis and Gooren (1999) to conclude that, ‘‘In
future research, as well as clinical practice, this important [typo-
logical] distinction should no longer be ignored’’(p. 322).
Typologies Based on Sexual Orientation In an analysis of 22 studies of MtF transsexuals and gender
dysphoric men from 16 countries, Lawrence (2008c) demon-
Studies conducted by Blanchard (1985, 1988, 1989a, b, 1991, strated that societal individualism was highly correlated with
1992, 1993a, b) illustrate the ability of transsexual typologies the percentage of nonhomosexual participants in the various
based on sexual orientation to facilitate research and provide countries. The observed association between the relative prev-
heuristic value. Blanchard’s (1985, 1988) observations of the alence of the two MtF transsexual subtypes and a societal factor
similarities between heterosexual, bisexual, and analloerotic/ that putatively influenced their expression was interesting and
asexual MtF transsexuals led him to formulate the concept of unexpected, again demonstrating the heuristic value of this
autogynephilia (Blanchard, 1989a, b) and to conclude that it was sexual orientation-based typology. It is also notable that Law-
central to the phenomenon of nonhomosexual MtF transsexu- rence was able to compile results from over 20 studies that used
alism. Blanchard (1991) subsequently proposed that autogy- reasonably comparable definitions of sexual orientation; it is
nephilia was a ‘‘misdirected form of heterosexual impulse’’ (p. difficult to imagine compiling a similar number of studies that
241). He also demonstrated that autogynephilia typically coex- employed reasonably comparable definitions of age of onset of
isted with heterosexual attraction but could also compete with it GID-related symptoms. This, too, testifies to the heuristic value
(Blanchard, 1992); and that, among autogynephilic men, auto- of typologies based on sexual orientation and their ability to
gynephilic fantasies of having a female body (Blanchard, 1993b), facilitate research.
and especially female genitals (Blanchard, 1993a), were most The observation that homosexual orientation is associated
strongly associated with gender dysphoria. with childhood gender-atypicality in MtF transsexuals (Freund
The understanding that heterosexual, bisexual, and anallo- et al., 1982; Johnson & Hunt, 1990) led Chivers and Bailey
erotic/asexual MtF transsexualism almost always involved the (2000) to investigate whether homosexual orientation is asso-
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ciated with childhood or adult gender-atypicality in FtM trans- original category names (homosexual, heterosexual, bisexual,
sexuals. Their specific findings—homosexual FtM transsexuals and asexual/analloerotic) or the equivalent names from the
were more gender-atypical for some, but not all, traits exam- DSM-IV (APA, 1994) and DSM-IV-TR (APA, 2000): attracted
ined—are less important than the fact that the extension to FtM to males, to females, to both, or to neither.
transsexuals of a sexual orientation-based typology developed for
MtF transsexuals yielded interesting and unexpected findings. Do Typologies Based on Sexual Orientation Lack
Clinical Utility?
Typologies Based on Age of Onset
Cohen-Kettenis and Pfäfflin (2009) argued that‘‘although sexual
It is difficult to find persuasive examples of the ability of typol- orientation subtyping may be of interest to researchers in the field,
ogies based on age of onset of GID-related symptoms to facil- no clinical decisions are currently based on this classification’’
itate research. The study by Doorn et al. (1994) probably offers and that ‘‘there are no convincing data on the clinical utility of
the best example: The authors found some expected associa- both subtypes’’(i.e., of either typology). They appeared to con-
tions between age of onset of gender dysphoria and other vari- clude, therefore, that typologies based on sexual orientation lack
ables of interest (i.e., some cross-gender play preferences and clinical utility. In my opinion, such a conclusion would be
heterosexual interest in adolescence), but failed to find other inaccurate. It may be true that, in most treatment centers, deci-
expected associations (i.e., prevalence of cross-dressing and sions concerning approval for hormone therapy and SRS no
extent of fetishistic cross-dressing). In this case, a typology longer take sexual orientation into account. Nevertheless, homo-
based on age of onset of GID-related symptoms can be seen as sexual and nonhomosexual MtF transsexualism are associ-
offering at least limited heuristic value. ated with different prognoses for some outcomes and arguably
deserve somewhat different case conceptualizations. Most
reported cases of regret among MtF transsexuals, for example,
Other Theoretical and Practical Considerations have involved nonhomosexual patients (e.g., Blanchard et al.,
Regarding Typologies Based on Sexual Orientation 1989; Kuiper & Cohen-Kettenis, 1998; Olsson & Möller, 2006;
versus Age of Onset Pfäfflin, 1992; Smith et al., 2005a; Wålinder et al., 1978; but
see Landén et al., 1998; Lawrence, 2003; Muirhead-Allwood
Many of the issues addressed in this section were raised by et al., 1999); consequently, clinicians might wish to emphasize
Cohen-Kettenis and Pfäfflin (2009), who commented on an early the possibility of regret with their nonhomosexual MtF clients
draft of the present article. Others were suggested as appropriate especially. In contrast, three studies (Kockott & Fahrner, 1988;
topics for discussion as part of the peer review process. Lawrence, 2005; Lewins, 2002) have suggested that homo-
sexual MtF transsexuals have greater difficulty establishing
Is There No Agreement Concerning the Number and Kind stable, long-term relationships with partners of their preferred
of Relevant Transsexual Subtypes? sex than do their nonhomosexual counterparts; clinicians might
wish to emphasize the possibility of problems in achieving long-
Cohen-Kettenis and Pfäfflin (2009) asserted that ‘‘in clinical term partnerships with their homosexual MtF clients especially.
writings, there seems to be agreement that transsexual subtypes Lawrence (2009c) suggested that nonhomosexual MtF trans-
do exist, although there is no agreement on the number and kind sexualism, in contrast to its homosexual counterpart, could be
of relevant subtypes.’’ In my opinion, their statement is only understood as a paraphilic phenomenon, with implications for
partly correct. For typologies based on age of onset of GID- case conceptualization in relation to issues such as investigating
related symptoms, there is indeed little agreement about which comorbid paraphilias, interpreting interactions with male sexual
symptoms are most relevant or about the most appropriate divid- partners, and understanding responses to cross-sex hormone
ing point between early and late onset; but typologies based on therapy.
age of onset, while still in use, have been largely supplanted by
typologies based on sexual orientation. For the latter typologies, Does Alleged Resistance by the Transsexual Community
Blanchard’s (1989a) fundamental distinction between homo- Pose Serious Difficulties for Typologies Based on Sexual
sexual and nonhomosexual MtF transsexuals has been widely Orientation?
adopted in recent years (e.g., by Berglund et al., 2008; Garcia-
Falgueras & Swaab, 2008; Johansson et al., 2009; Lawrence, Cohen-Kettenis and Pfäfflin (2009) alleged that ‘‘in the trans-
2005, 2008c; Smith et al., 2005a, b) and has been applied to FtM gender community, there is strong resistance against subtyping
transsexuals as well (e.g., by Chivers & Bailey, 2000; Johansson on the basis of sexual orientation and activity and even against
et al., 2009; Smith et al., 2005a, b). When a four-category having to give this information for scientific purposes only.’’
typology based on sexual orientation is indicated, Blanchard’s They proposed that, given the controversy surrounding the
(1989a) categories are almost always employed, using either his concept of autogynephilia, which some transgender persons
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540 Arch Sex Behav (2010) 39:514–545
consider offensive, and the association of this concept with reviewer of an earlier draft of this article, I will briefly address
typologies based on sexual orientation, ‘‘It is therefore likely this issue.
that…increased awareness regarding the sexual orientation Winters (2008), cited by Cohen-Kettenis and Pfäfflin (2009),
issue has led to less reliable reports of sex reassignment appli- set forth most of the objections that MtF transsexuals typically
cants on their sexual orientation.’’It was even possible, Cohen- offer concerning the concept of autogynephilia and the trans-
Kettenis and Pfäfflin suggested, that ‘‘sexual orientation has sexual typology informed by it. As the title of her essay suggests,
become so controversial that, in a clinical setting, the informa- Winters’ principal objections are that autogynephilia and its
tion given by applicants for medical interventions may have associated typology are ‘‘infallible’’ (i.e., unfalsifiable) and
become invalid.’’ In other words, Cohen-Kettenis and Pfäfflin ‘‘derogatory.’’ Winters’ allegation of unfalsifiability is perhaps
argued that, due to the controversy surrounding autogynephilia not central to the issue at hand, but it can be quickly dismissed as
and typologies based on sexual orientation, transsexual patients inaccurate: One can easily imagine several kinds of evidence
might either refuse to provide information about their sexual that could, in principle, falsify Blanchard’s theory of autogy-
orientation or else might deliberately provide inaccurate infor- nephilia.2 Winters’ allegation that autogynephilia and its asso-
mation, thereby limiting the usefulness of typologies based on ciated typology are derogatory is really at the heart of the matter.
this criterion. I will address these two possibilities separately. She characterizes the concept and the typology as ‘‘offensive’’
Is there evidence that significant numbers of transsexual (} 7),‘‘stigmatizing and dehumanizing’’(} 7), and‘‘an affront to
patients are refusing to provide information about their sexual human legitimacy and dignity’’(} 10). Fundamentally, her com-
orientation, either because they object to the concept of auto- plaint is that Blanchard’s theory of autogynephilia conceptu-
gynephilia or for any other reason? I have found no published alizes some MtF transsexuals differently than they conceptu-
reports documenting such a phenomenon. Several recently alize themselves: as‘‘homosexual men’’(} 10) or as men‘‘moti-
published studies in which MtF transsexual participants have vated…primarily by sexual paraphilia’’ (} 10), rather than as
been asked about their sexual orientation contain no descrip- transsexual women motivated by ‘‘an inner feminine gender
tions of such refusals. For example, Sánchez and Vilain (2009) identity or ‘essence’’’(} 10).
did not describe any refusals to report sexual orientation among Objections of this kind do not, in my opinion, constitute
the 53 MtF transsexual participants they surveyed, nor did strong arguments against transsexual typologies based on sex-
Berglund et al. (2008), Gizewski et al. (2008), or Luders et al. ual orientation. The history of science contains many examples
(2009) among the MtF patients they studied (12, 12, and 24 of theories that offered substantial explanatory value but were
participants, respectively). criticized and sometimes temporarily suppressed because they
Is there evidence that transsexuals, offended by the concept challenged people’s self-concepts. The theories of Galileo and
of autogynephilia or by the typology linked to it, are deliberately Darwin come readily to mind: These theories, too, undoubtedly
providing misinformation about their sexual orientation? Such were once considered offensive, stigmatizing, dehumaniz-
occurrences might be difficult to detect and would be virtually ing, and an affront to human dignity by people accustomed to
impossible to disprove. But the phenomenon of transsexuals thinking of themselves as occupying the center of the universe or
lying about or otherwise misrepresenting their sexual orienta- as being the result of a special creation. I have argued (Law-
tion certainly would not be anything new: As noted previously, rence, 2008b) that theories that challenge the self-concepts of
clinicians have recognized for decades that transsexual patients MtF transsexuals have the potential to inflict narcissistic injury
sometimes lie about (Walworth, 1997) or otherwise misreport (see Kohut, 1972) and that clinicians and scholars have an
(Freund, 1985; Lawrence, 2008a; Meyer et al., 2001) their obligation to be mindful of this possibility in their choice of
sexual orientation, albeit for different reasons than Cohen- descriptive language, to avoid inflicting such injury unneces-
Kettenis and Pfäfflin implicitly suggested. Fortunately, again as sarily on a vulnerable population. But such an obligation would
previously noted, objective information about marriage and part- not, in my opinion, justify discarding typologies based on sexual
nership patterns can often be used to confirm or contradict self- orientation, given their substantial descriptive, explanatory, prog-
reported sexual orientation. Moreover, reasonably reliable objec- nostic, and heuristic value.
tive measures of sexual arousal and interest, including some uti-
lizing neuroimaging, are increasing available in research settings.
Cohen-Kettenis and Pfäfflin (2009) did not explicitly argue
that objections by transsexual persons to the concept of autogy-
nephilia and to typologies based on sexual orientation per 2
Examples would include repeated objective demonstration (not just
se constituted a disadvantage of such typologies. One might self-report) of sexual arousal with cross-dressing or cross-gender
reasonably infer this, however, from their observation that fantasy in significant numbers of gender dysphoric males who are
demonstrably androphilic, or repeated failure to objectively demon-
autogynephilia‘‘is considered highly offensive by some,’’in the
strate sexual arousal with cross-dressing or cross-gender fantasy in
context of a paragraph listing the disadvantages of typologies significant numbers of gender dysphoric males who are demonstrably
based on sexual orientation. In response to a request by a gynephilic.
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Arch Sex Behav (2010) 39:514–545 541
Does Self-Favorable Reporting to Obtain Access to Care relationships primarily or exclusively with women, during
Limit the Value of Typologies Based on Sexual adolescence and at 10-year follow-up; and one was exclusively
Orientation? attracted to women and apparently had relationships only
with women, during adolescence and at 10-year follow-up
Cohen-Kettenis and Pfäfflin (2009) suggested that one limita- (Diamond, 2008; Diamond & Butterworth, 2008). In summary,
tion of typologies based on sexual orientation is that‘‘it is likely there is no credible evidence of mutability of sexual orientation
that, depending on the criteria of access to treatment in a specific in adult males, including MtF transsexuals. Some adult females
treatment facility, applicants adjust their biographical data with arguably display at least limited mutability of sexual orientation,
respect to sexuality. This makes the quality of the information, but it is not known whether this is true of FtM transsexuals
especially when given during clinical assessment, question- specifically; evidence against this possibility is that the trans-
able.’’It is true that, in the past, self-favorable reporting of sexual gender-identified females described by Diamond (2008; Dia-
orientation (i.e., reporting an exclusively homosexual orienta- mond & Butterworth, 2008) reported little change in their sexual
tion) in order to obtain access to care posed a significant, albeit attractions and sexual partner choices over a 10-year study
not insurmountable, challenge for the accurate classification of period.
patients. This is less likely to be a significant problem nowadays,
however, because in most treatment programs, as Cohen- Is the Correlation Between Age of Onset and Sexual
Kettenis and Pfäfflin themselves observed, ‘‘no clinical deci- Orientation High Enough that the Former Can Substitute
sions are currently based on this classification.’’ for the Latter?
Cohen-Kettenis and Pfäfflin (2009) proposed that‘‘it would also

Does the Possible Mutability of Sexual Orientation be worthwhile to investigate the relationship between onset age
Create Problems for Typologies Based on Sexual and sexual orientation more extensively. If they are highly
Orientation? correlated and onset age has proven its clinical utility, onset age
rather than sexual orientation could be used.’’This relationship
Cohen-Kettenis and Pfäfflin (2009) suggested that ‘‘another has been investigated at least once: In a study of 25 MtF trans-
problem concerning the usefulness of sexuality-related GID sexuals, Johnson and Hunt (1990) found that gynephilia (argu-
specifiers regards the stability of sexual orientation.’’They cited ably the best indicator of sexual orientation in their study)
research by Diamond (2000; Diamond & Butterworth, 2008) in showed a nonsignificant correlation, -.04, with age of onset
support of the idea that‘‘there is considerable fluidity in sexual of cross-dressing or cross-gender fantasies; the correlation
orientation, especially for women.’’ Here again, I believe that between androphilia and age of onset was of greater magnitude
Cohen-Kettenis and Pfäfflin have overstated the case. As noted (-.18) but again nonsignificant. In a recent study of MtF
earlier, sexual orientation in males appears to be essentially transsexuals, Johansson et al. (2009) did not report a correlation
unchangeable in adulthood (Harry, 1984; Pillard & Bailey, between sexual orientation and age of onset of gender dys-
1995; Swaab, 2007), despite some reported changes in sexual phoria, but, as previously noted, a four-fold point correlation
self-identification and in the sex of chosen partners. In the only coefficient can easily be calculated from their tabular data and
laboratory study (Lawrence et al., 2005) of a MtF transsexual was fairly low: .21. These low correlations should not be sur-
who reported a change in sexual orientation following SRS, prising: Although homosexual MtF transsexuals, on average,
subjective and objective measures of sexual arousal were incon- report an earlier age of onset of GID-related symptoms than their
sistent with the supposed change in orientation. The studies by nonhomosexual counterparts, between-group differences tend
Diamond (2000; Diamond & Butterworth, 2008), cited by to be small. For example, Blanchard et al. (1987) found that
Cohen-Kettenis and Pfäfflin, described‘‘sexual fluidity’’only in homosexual MtF transsexuals reported first cross-gender
females, not in males. It is also notable that 4 of the 89 non- wishes at an average age of 7.7 years, versus 9.8 years for non-
heterosexual females whom Diamond (2008) followed longi- homosexual MtF transsexuals. Lawrence (2005) observed that,
tudinally eventually adopted complete or partial transgender among MtF transsexuals who reported either consistent homo-
identities and that these individuals—in contrast to most of sexual (n = 17) or heterosexual (n = 50) attractions before and
Diamond’s other participants—displayed little evidence of sex- after sex reassignment, mean ages of onset of gender dysphoria
ual fluidity. Two of these transgender-identified females were were 6.3 and 8.0 years, respectively; for the two groups com-
attracted to both men and women and had relationships with bined (n = 67), the point-biserial correlation between sexual
both men and women, during adolescence and at 10-year fol- orientation and age of onset (not originally reported, but calcu-
low-up; one was attracted to both men and women but had lated for this article) was .14.
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542 Arch Sex Behav (2010) 39:514–545
Have Typologies Based on Age of Onset Been lescence or young adulthood. To date, however, fewer than 50
Inadequately Studied? Should the DSM-V Employ One such patients have been described (Cohen-Kettenis, 2001;
of These Typologies, Simply Because They Deserve Wallien & Cohen-Kettenis, 2008; Zucker & Bradley, 1995).
More Study? This cohort of patients presumably informed Cohen-Kettenis
and Pfäfflin’s conjecture that it might be useful to‘‘differentiate
Citing an early draft of the present article, Cohen-Kettenis and between onset in various phases (e.g., very early childhood
Pfäfflin (2009) claimed that ‘‘Lawrence also indicates that [before the age of about three years], childhood until puberty,
onset age [as a basis for typologies] has hardly been studied, adolescence, and adulthood).’’ The existence of these persis-
because, historically, there was more scientific interest in tently gender dysphoric young patients suggests that age of
sexual orientation.’’ They went onto argue that ‘‘it is the onset can still be an important consideration in GID; but it does
importance of onset age for the long-term development of nothing to improve the limited reliability, predictive value, and
gender dysphoric individuals we need to know much more heuristic value of typologies based on this criterion. Cohen-
about’’and, therefore, that‘‘it is likely that a specifier focusing Kettenis and Pfäfflin are correct that the age of onset of GID-
on onset age, provided that it is clearly defined and well related symptoms deserves further study; this does not imply,
measured, will contribute even more to our understanding of however, that age of onset should replace sexual orientation as
gender dysphoria than sexual orientation.’’ the basis for a typology for GID in the DSM-V.
Cohen-Kettenis and Pfäfflin (2009) evidently misunderstood
my findings: I summarized 15 typologies based on age of onset
of GID-related symptoms (14 listed in Table 2, plus Cohen- Summary and Conclusion
Kettenis et al., 1998, listed in Table 4), versus only 10 based on
sexual orientation (9 listed in Table 1, plus Chivers & Bailey, Transsexual typologies based on sexual orientation have
2000, listed in Table 4). This does not suggest that the former been in use longer than typologies based on age of onset of
typologies have‘‘hardly been studied.’’Indeed, one could make GID-related symptoms and have been more widely used in
the case that, from the mid-1970s into the early 1990s, typolo- studies published during the last decade. For both typologies,
gies based on age of onset were dominant: They received greater subtype assignment based on self-report is relatively easy,
attention and were more widely used than typologies based on but the reliability of subtype assignment via self-report is not
sexual orientation, despite the inclusion of the latter typologies outstanding for either typology. Objective measures, how-
in the DSM. Typologies based on sexual orientation did not ever, can confirm or contradict self-reported sexual orienta-
achieve their current dominant status until the studies conducted tion; methods to confirm or contradict self-reported age of
by Blanchard (1985, 1988, 1989a, b; Blanchard et al., 1987) onset involve significant limitations. Typologies based on
were published and came to the attention of clinicians and sexual orientation employ subtypes that are less ambiguous
researchers. Typologies based on age of onset have not been than typologies based on age of onset and that are better at facili-
neglected; they have been abandoned (or largely so), and for tating concise, comprehensive clinical description. Typologies
good reasons: They are inferior in reliability and in descriptive, based on sexual orientation are superior in their ability to predict
prognostic, and heuristic value. treatment-related outcomes and comorbid psychopathology and
If Cohen-Kettenis and Pfäfflin (2009) genuinely believed to facilitate research. Commonly expressed objections to typol-
that typologies based on age of onset had been inadequately ogies based on sexual orientation and arguments in favor of
studied, then they surely took an unusual stance in recom- typologies based on age of onset are unpersuasive when exam-
mending the adoption of such an unproven typology, simply ined closely. The forthcoming edition of the DSM should con-
because it had been inadequately studied. I would argue that tinue to employ subtypes based on sexual orientation for the diag-
typologies based on age of onset have not been inadequately nosis of GID in Adolescents or Adults or its successor diagnosis.
studied: They have been studied and found to be inadequate. In
either case, however, it is difficult to reconcile Cohen-Kettenis
and Pfäfflin’s recommendation of such a typology with the
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DOI 10.1007/s10508-009-9524-4
ORIGINAL PAPER
Familiality of Gender Identity Disorder in Non-Twin Siblings

Esther Gómez-Gil Æ Isabel Esteva Æ M. Cruz Almaraz Æ
Eduardo Pasaro Æ Santiago Segovia Æ Antonio Guillamon
Received: 11 August 2008 / Revised: 3 February 2009 / Accepted: 17 May 2009 / Published online: 29 July 2009
Abstract Familial studies and reports of co-occurrence of of transsexuals, and for siblings of MF than FM transsexuals.
gender identity disorder (GID) within a family may help to Nevertheless, the risk is low.
clarify the question of whether transsexualism is a familial
phenomenon. In a sample of 995 consecutive transsexual Keywords Transsexualism Gender identity disorder
probands (677 male-to-female [MF] and 318 female-to-male Familial studies Genetics
[FM]), we report 12 pairs of transsexual non-twin siblings
(nine pairs of MF siblings, two pairs of MF-FM siblings, and
one pair of FM siblings). The present study doubles the number Introduction
of case reports of co-occurrence of transsexualism in non-
twin siblings available in the literature. According to our Gender identity disorder (GID), as defined by the Diagnostic and
data, the probability that a sibling of a transsexual will also be Statistical Manual of Mental Disorders (DSM-IV) (American
transsexual was 4.48 times higher for siblings of MF than for Psychiatric Association, 1994), has two main characteristics: a
siblings of FM transsexual probands, and 3.88 times higher strong and persistent cross-gender identification and persis-
for the brothers than for the sisters of transsexual probands. tent discomfort with the individual’s assigned gender. The
Moreover, the prevalence of transsexualism in siblings of term GID in adolescents or adults, also referred to as trans-
transsexuals (1/211 siblings) was much higher than the range sexualism in the ICD-10 (World Health Organization, 1993),
expected according to the prevalence data of transsexualism can be defined as an extreme form of gender dysphoria. Al-
in Spain. The study suggests that siblings of transsexuals may though the etiology of GID is unknown, it has been suggested
have a higher risk of being transsexual than the general that biological and environmental factors could contribute to
population, and that the risk is higher for brothers than sisters gender identity variations (for a review, see Gooren, 2006).
The biological line of research has focused on neuroana-
tomical (Kruijver et al., 2000; Zhou, Hofman, Gooren, &
E. Gómez-Gil (&) Swaab, 1995), hormonal (Swaab, 2004), and genetic influ-
Unidad de Identidad de Género, Instituto Clı́nic de Neurociencias, ences. The research into genetic determinants has come from
Servicio de Psiquiatrı́a, Hospital Clı́nic, Universidad de Barcelona,
familial, twin, molecular, and chromosomal studies.
Villarroel 170, 08036 Barcelona, Spain
e-mail: [email protected] Familial studies and reports of co-occurrence of GID may
help to partially explain the etiology of these disorders. Nev-
I. Esteva M. C. Almaraz ertheless, to our knowledge, no familial studies on transsexu-
Unidad de Trastornos de Identidad de Género, Servicio
alism have been carried out and only several small series
de Endocrinologı́a, Hospital Carlos Haya, Málaga, Spain
involving non-twin siblings have been published. There are
E. Pasaro reports of seven pairs of male-to-female (MF) (Ball, 1981;
Departamento de Psicobiologı́a, Universidad de A Coruña, Green, 2000; Hore, Nicolle, & Calnan, 1973; Sabalis, Frances,
A Coruña, Spain
Appenzeller, & Moseley, 1974; Stoller & Baker, 1973), two
S. Segovia A. Guillamon pairs of female-to-male (FM) (Green, 2000; Joyce & Ding,
Departamento de Psicobiologı́a, UNED, Madrid, Spain 1985), and one pair of MF-FM transsexual non-twin siblings
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Arch Sex Behav (2010) 39:546–552 547
(Green, 2000). The only published study of transsexual sib- distribution of the estrogenic receptor gene polymorphisms
lings or family members from a large sample (1,500 patients) was similar to that in controls (Sosa et al., 2004). Henningsson
was by Green (2000). Therefore, it is unknown whether there is et al. (2005) found significant partial effects for the risk of
a familial association on GID. developing transsexualism on the interaction between three
Twin studies are needed to disentangle the roles of genetic polymorphisms related to the androgen, beta estrogen, and
and environmental influences in the etiology of this disorder. aromatase genes. The data obtained in studies of transsexual
Nevertheless, because the prevalence of transsexualism is low populations indicate that the A2 variant of the CYP17 gene,
(Michel, Mormont, & Legros, 2001), these studies are scarce which intervenes in the synthesis of dihydroepiandrosterone
and are based mainly on twin case reports. In MF transsexu- and 17-hydroprogesterone, might be involved in the etiology
alism, there are reports of six monozygotic (MZ) twin pairs of MF transsexualism (Bentz et al., 2008). Recently, Hare et al.
concordant for transsexualism (Anchersen, 1956; Gooren, (2009) found a significant association between longer andro-
Frantz, Eriksson, & Rao, 1989; Green, 2000; Hyde & Kenna, gen receptor gene polymorphisms and MF transsexualism.
1977; Tsur, Borenstein, & Seidman, 1991; Zucker & Bradley, However, these results should be considered with caution,
1995), five MZ twin pairs discordant for transsexualism since the statistical treatment was performed at the population
(Gooren et al., 1989; Green & Stoller, 1971; Hepp, Milos, & level rather than the individual level.
Braun-Sharm, 2004; Zucker & Bradley, 1995), and one report Chromosomal abnormalities have also been found in trans-
of two dizygotic (DZ) transsexual male triplets with a non- sexual individuals (for a review, see Swaab, 2004). Several
transsexual female co-triplet (McKee, Roback, & Hollender, cases of MF transsexuals with 47,XYY (Buhrich, Barr, & Lam-
1976). In FM transsexual twins, one concordant (Sadeghi & Po-Tang, 1978; Haberman, Hollingsworth, Falek, & Michael,
Fakhrai, 2000) and four discordant MZ pairs (Garden & 1975; Snaith, Penhale, & Horsfield, 1991; Taneja, Ammini,
Rothery, 1992; Green & Stoller, 1971; Segal, 2006) have been Mohapatra, Saxena, & Kucheria, 1992; Wagner, 1974) and
reported. Moreover, most of the MZ and DZ twin case reports female-to-male 47,XXX chromosome karyotypes have been
share not only genes but also many environmental factors. reported (Turan et al., 2000). Because the 47,XYY karyotype
Therefore, it is not possible to identify the roles of different occurs in approximately 1 in every 800 to 1000 male newborns,
genetic influences on the basis of these case reports. and the 47,XXX occurs in 1 in every 1000 female newborns
The heritability of GID or related traits (childhood gender (Grumbach, Hughes, & Conte, 2003), these cases may only
nonconformity and atypical gender role development) has represent a random association with transsexualism. Hen-
been assessed in three twin studies. In a retrospective study of gstschläger et al. (2003) analyzed G-banded karyotypes of 30
1,891 adult twins, Bailey, Dunne, and Martin (2000) found a MF and 31 FM transsexuals and found no chromosomal aber-
significant heritable pattern for childhood gender nonconfor- ration in these individuals with the exception of one balanced
mity for both men and women, although the heritability esti- translocation 46,XY, and no evidence of molecular-cytogenetic
mates were stronger in men. In another study conducted with a alterations affecting either the androgen receptor gene region
sample of parents of 96 MZ and 61 DZ pairs of twins who locus on chromosome Xq12 or the sex-determining region of
completed a neuropsychological inventory to examine the the Y chromosome.
prevalence of clinically significant GID symptomatology in In summary, the evidence for genetic influences on GID
their twins, Coolidge, Thede, and Young (2002) found that a from family, twin, molecular genetic, and chromosomal
genetic component accounted for 62% of the variance. Both studies is limited. We concur with Green (2000) that the rarity
studies support the hypothesis that childhood nonconformity of transsexualism makes studying families whose members
and GID symptomatology have a strong heritable component. show the phenomenon worthwhile, and that the creation of a
However, in a genetic study of atypical gender role develop- database would contribute to research in this field.
ment in 5,799 pairs of child-age twins, Knafo, Iervolino, and The aim of our study was to describe the family co-occur-
Plomin (2005) asked parents to rate the masculinity and fem- rence of transsexualism in a sample of 995 Spanish transsexual
ininity of their twins, and found that the extent of shared patients in order to determine whether there was a familial
environmental effects was stronger than genetic effects in most association in non-twin siblings of individuals with transsexu-
cases (except for masculine girls, in whom group heritability alism.
accounted for most of the variance).
Molecular genetic studies can identify genetic markers of
vulnerability or resilience. To our knowledge, three studies so Method
far have reported the association between transsexualism and
certain polymorphisms. All used case-control candidate gene Participants
association and focused on androgen and estrogen system
genes. In a group of MF transsexuals who had been taking The study population comprised 995 transsexual probands
estrogens and anti-androgens for a minimum of 3 years, the (677 MF and 318 FM) from two gender identity disorders
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548 Arch Sex Behav (2010) 39:546–552
units in the Spanish public health system. One is in the region transsexual non-twin siblings (9 MF and 2 FM siblings).1 The
of Andalusia (Unidad de Trastornos de Identidad de Género percentage of MF probands with a non-twin transsexual
(UTIG), Hospital Carlos Haya, Malaga) and the other in sibling was thus 1.6%.
Catalonia (Unidad de Identidad de Género (UIG), Hospital
Clı́nic, Barcelona) (Gómez-Gil & Esteva de Antonio, 2006). Estimation of the Probability that a Sibling of a MF
Both units provide specialized, comprehensive psychiatric- Transsexual will also be Transsexual
psychological and endocrine therapy for transsexual patients.
Surgical treatment is provided from the UTIG since 2000, The number of biological siblings was obtained in a subsample
and from the UIG from January 2009. The database of each of 333 probands. For this subsample, the total number of bio-
unit was set up in 2000 and this study included all patients logical siblings through the mother was 883 (474 brothers and
evaluated as of March 2008. Both gender identity teams 409 sisters). Using an estimation of the number of biological
adopted the Standards of Care guidelines of the World Pro- siblings, for the total sample of 677 MF probands, the number of
fessional Association for Transgender Health (Meyer et al., estimated biological siblings would be 1795 (n = 964 brothers
2001). and n = 831 sisters) (Table 2). Thus, the probability that a
sibling of a MF transsexual would also be transsexual was
0.0061 (11:1795).
Measures and Procedure
Female-to-Male Probands
Each patient completed several semi-structured clinical inter-
views performed independently by a psychiatrist and then a
Number of Transsexual Non-Twin Siblings
psychologist, both with several years of experience in GID
diagnosis. The diagnoses were made using the DSM-IV (Amer-
Of our 318 FM probands, we found one FM non-twin sibling
ican Psychiatric Association, 1994) and ICD-10 criteria (World
(Table 1). Thus, the percentage of FM probands with a non-
Health Organization, 1993). For all cases of GID included in this
twin transsexual sibling was 0.3%, 5.3 times lower than the
report, the two experts discussed the case prior to agreeing on the
percentage of MF probands.
diagnosis.
Sociodemographic, clinical, and psychiatric data that in-
Estimation of the Probability that a Sibling of a FM
cluded any family background of GID were completed for all
Transsexual would also be Transsexual
patients as part of similar standard clinical assessments at both
clinics (Bergero Miguel et al., 2001; Esteva et al., 2001;
For a subsample of 169 FM probands, we found 389 biological
Gómez-Gil, Trilla, Salamero, Godás, & Valdés, 2009). For
siblings (193 brothers and 196 sisters). Using an estimation of
patients with a family background of transsexualism, the
the number of biological siblings, for the total sample of 318
variables selected from the clinical history were age at first
FM probands the number of biological siblings would be 732
request in the unit, age when they realized gender noncon-
(n = 363 brothers and n = 369 sisters). Thus, the probability
formity (childhood onset), age at beginning hormonal therapy
that a sibling of a FM transsexual would also be transsexual
(with or without prescription), sex-reassignment surgeries,
was 0.0014 (1:732) (Table 2).
and sexual orientation. Sexual orientation was established by
asking what partner (a man, a woman, both or neither) the
Total Probands
patient would prefer or feel attraction to if they were com-
pletely free to choose and the body did not interfere. The same
Differential Risk of Transsexualism in Brothers and Sisters
information about any relative who was reported as transsex-
of MF and FM Transsexuals
ual but had not been treated at the unit was obtained from the
probands or family of probands.
The probability that a sibling of a MF transsexual will also be
transsexual (0.0061) was nearly 4.48 times higher than the
probability for a sibling of a FM transsexual (0.0014). The
Results probability that a sibling of a MF transsexual proband will
Male-to-Female Probands
Number of Transsexual Non-Twin Siblings 1

Data of other familial case reports from that population (two pairs of
DZ twin siblings, eight pairs of first and second cousins, and three MF
The main characteristics of transsexual sibling pairs are probands who have an uncle concordant for MF transsexualism) are
shown in Table 1. Of our 677 MF probands, we found 11 available from the corresponding author upon request.
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Arch Sex Behav (2010) 39:546–552 549
Table 1 Case reports with co-occurrence of MF and/or FM transsexualism among siblings in two Spanish gender teams units
Diagnosis Age at first Childhood Age at onset Surgery (age when Sexual
request onset hormonal therapy performed) orientation
Transsexual siblings of male-to-female probands

Pair 1 MF 21 Yes 12b VAG (23) Males
a
MF 23 Yes 14b VAG Males
Pair 2 MF 33 Yes 20 BRE (28), VAG (35) Males
MF 35 Yes 22 VAG (38) Males
Pair 3 MF 29 Yes 15b BRE (18), ORQ (27), Males
FAC (28), VAG (29)
MFa 36 Yes 15b BRE (18), VAG (22) Males
MFa 54 Yes Unknown VAG Males
b
Pair 5 MF 18 Yes 17 VAG, BRE Males
MFa Older Yes 14b VAG, BRE Males
Pair 6 MF 15 Yes 13b VAG Males
MFa 20 Yes 15b VAG Unknown
Pair 7 MF 17 Yes None None Males
a b
MF 30 Yes 29 None Males
Pair 8 MF 31 Yes 21b None Males
MFa 45 Yes Unknown VAG Males
Pair 9c MF 17 Yes 15b BRE (16), VAG (18) Males
MF 18 Yes 15b VAG (19) Males
Pair 10 MF 36 Yes 15b None Males
a
FM 52 Yes None None Females
a
FM 36 Yes None None Females
Transsexual siblings of female-to-male probands
Pair 1 FM 26 Yes 27 MAS (30) Females
FM 29 Yes 30 MAS (34) Females
MF male-to-female transsexual, FM female-to-male transsexual; Surgeries performed: BRE breast implant, FAC facial plastic surgery, MAS
mastectomy, ORQ orchiectomy, VAG vaginoplasty
a
Report = information obtained by the transsexual proband or family
b
Started taking hormones on their own without prescription
c
Shared mother
also be transsexual was 3.88 times higher for the brothers Catalonia, the prevalence has been estimated as 1/21,031 men
(9:964) than for the sisters (2:831) (Table 2).2 and 1/48,096 women (Gómez-Gil et al., 2006). The estimated
prevalence of transsexualism in siblings of transsexuals in our
Prevalence of Transsexualism in Siblings of Transsexual sample was much higher than that expected in the general
Probands and Comparison with Prevalence Data population in Spain.3
in the General Population
The prevalence of transsexualism in siblings of transsexual Discussion

probands was 1/211 (12:2527) (Table 2). According to health
care demand, the prevalence of transsexualism in Andalusia The present case series adds nine cases of MF transsexual
has been estimated as 1/9,658 men for MF and 1/15,456 siblings to the seven already reported in the literature (Ball,
women for FM transsexualism (Esteva et al., 2006). In 1981; Green, 2000; Hore et al., 1973; Sabalis et al., 1974;
2 3
Data on siblings of FM probands were not compared, since only one Statistical comparison of two proportions was not performed because
familial case has been described. of the low prevalence data in the general population.
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550 Arch Sex Behav (2010) 39:546–552
Table 2 Number of transsexual

Number of transsexual Number of transsexual
siblings from the total number
siblings:number of siblings:number of
of siblings of MF and FM
estimated biological estimated biological
transsexual probands
siblings of 677 MF siblings of 318 FM
according to sex
probands probands
Biological brothers 9:964 0:363

Biological sisters 2:831 1:369
Total 11:1795 = 0.0061 1:732 = 0.0014 12:2527 = 1:210,58 siblings
Stoller & Baker, 1973), two pairs of MF and FM transsexual vulnerability to transsexualism. This sex difference is replicated
siblings respectively to the case of MF transsexual with a in siblings of transsexuals. In fact, the probability that a sibling
gender dysphoric sister described by Green (2000), and a pair of a MF transsexual will also be transsexual was 3.88 times
of FM transsexual siblings to the case also described by Green higher for brothers than sisters, and 4.48 times higher than in the
(2000). The present report doubles the existing literature of case of a sibling of a FM transsexual. Male siblings and siblings
familial cases of non-twin transsexual siblings. of MF transsexuals are at a higher risk of transsexualism than
The only published study of sibling or family co-occur- female siblings and siblings of FM transsexuals. Green (2000)
rence of gender dysphoria from a large sample of about 1,500 has suggested a genomic imprinting mechanism to explain the
patients is by Green (2000). In his sample, Green found 6 higher proportion of MF than FM transsexuals; if so, some genes
pairs of transsexual siblings (5 pairs of non-twin and 1 pair of in the chromosome may predispose the sons to feminization and
twin). In our study, from a sample of 995 patients, we found the subsequent development of transsexualism. The possibility
14 pairs of transsexual siblings (12 non-twins and 2 twins). of a genetic biological factor in the etiology of at least some
The higher proportion of cases in our study compared with cases of transsexualism should be considered. Nevertheless, our
Green’s study may be due to the fact that the total number results do not explain the etiology of transsexualism in a
of siblings in our population was larger than in his English straightforward way. The sexual differentiation of the brain and
population. behavior appears to be a very complex multi-signaling process
The estimated prevalence of transsexualism for non-twin involving genetic, hormonal, neural, and environmental vari-
siblings of transsexuals in our sample (1/211 siblings) is ables (Segovia et al., 1999).
much higher than the prevalence of transsexualism expected The present study had a number of limitations. First, the
in the general population according to the prevalence data of clinical assessment of family members with transsexualism or
transsexualism in the Spanish population (Gómez-Gil et al., GID who were not patients at these clinics was collected indi-
2006). Spanish data on the prevalence of transsexualism were rectly from the transsexual probands, meaning that the diagnosis
in line with previous literature (Michel et al., 2001). There- may be less reliable. Nevertheless, a diagnosis of transsexualism
fore, our study data suggest that siblings of transsexuals are at is highly probable since almost all these transsexual members
a high risk for the disorder compared with the general pop- were in hormonal therapy and had undergone vaginoplasty.
ulation. Therefore, transsexualism may be familial. Never- Second, we did not analyze environmental influences. Never-
theless, the absolute percentage is quite low. theless, studies reporting parental influences have no solid
This result corroborates the fact that siblings of transsex- empirical support, and there are no studies of the influence of
uals are more likely than the general population to share broader societal influences on GID (Cohen-Kettenis & Gooren,
factors that influence the disorder. Therefore, an etiological 1999). Moreover, the clinical impressions of the authors who
mechanism appears to be common in different populations. attended transsexual patients are that these patients’ parents did
Nevertheless, family studies cannot tell us whether a disorder not present more psychopathology, divorce, or familial trauma
runs in families due to environmental factors, biological than the general population. Third, Blanchard and others have
factors, or both. Twin studies are needed to identify the role of stressed the importance of distinguishing between homosexual
genetic and environmental influences in disorder etiology, and non-homosexual transsexuals, suggesting that each group
but are limited to the case reports described above (Green, has a possibly separate etiology (Blanchard & Sheridan, 1992).
2000; Segal, 2006), and to analyses of the heritability of Since previous research in a Spanish population found high
gender nonconformity or sex-typed behaviors in children proportions of MF (89.9%) and FM (94.4%) transsexuals
(Bailey et al., 2000; Coolidge et al., 2002; Knafo et al., 2005). reporting same-sex sexual orientation (Gómez-Gil et al., 2009)
Neither our data nor these studies identify the role of genetic compared with previous European studies (Lawrence, 2008),
or other influences in the etiology of the disorder. we did not consider that the lack of a separate analysis of sexual
Our ratio of MF:FM probands (2.13:1), in agreement with the orientation would change our findings. Finally, the total number
literature (Michel et al., 2001), suggests a sex difference in the of biological siblings of the probands was estimated from the
123
Arch Sex Behav (2010) 39:546–552 551
real number of siblings in a subsample of probands, which did en Andalucı́a (Málaga) [Endocrinological evaluation and hormone
not include those with a transsexual sibling. treatment of transsexuality by the Andalusian Gender Identity
Disorder Unit in Malaga (Spain)]. Cirugıá Plástica Ibero-latino-
In summary, we found a higher familial risk for trans- americana, 27, 273–280.
sexualism in siblings of transsexuals than in the general popu- Esteva, I., Gonzalo, M., Yahyaoui, R., Domı́nguez, M., Berguero, T., &
lation, in siblings of MF than FM transsexuals, and in brothers Giraldo, F. (2006). Epidemiologı́a de la transexualidad en And-
than in sisters of transsexuals. As Green (2000) and Segal alucı́a: especial atención al grupo de adolescentes [Epidemiology
of transsexualism in Andalusia: Special attention to the adolescent
(2006) have noted, we also think that it is important to create a group]. Cuadernos de Medicina Psicosomática, 78, 65–70.
database of individuals with GID as well as a DNA bank of Garden, G. M., & Rothery, D. J. (1992). A female monozygotic twin pair
blood samples from these subjects (and mainly from familial discordant for transsexualism. Some theoretical implications.
cases with a large number of their family members), so as to British Journal of Psychiatry, 161, 852–854.
Gómez-Gil, E., & Esteva de Antonio, I. (2006). Ser transexual [Being
be able to design future studies that might identify molecular transsexual]. Barcelona: Editorial Glosa.
markers. A bank of this kind would provide us with a suffi- Gómez-Gil, E., Trilla, A., Salamero, M., Godás, T., & Valdés, M.
ciently large number of cases to be able to propose verifiable (2009). Sociodemographic, clinical, and psychiatric characteris-
hypotheses regarding the possible genetic cause of gender tics of transsexuals from Spain. Archives of Sexual Behavior, 38,
378–392.
identity disorders in at least some families. Gómez-Gil, E., Trilla-Garcı́a, A., Godás-Sieso, T., Halperin-Rabino-
vich, I., Puig Domingo, M., Vidal Hagemeijer, A., et al. (2006).
Acknowledgements We are thankful to the patients and their families Estimación de la prevalencia, incidencia y razón de sexos del
for their cooperation. The work of AG, EG, EP and SS is supported by transexualismo en Cataluña según la demanda asistencial [Esti-
grants SEJ2007-65686/PSIC, SAF2004-22551-E and PI-0254/2007 JA. mation of prevalence, incidence and sex ratio of transsexualism in
Catalonia according to health care demand]. Actas Españolas de
Psiquiatrıá, 34, 295–302.
Gooren, L. (2006). The biology of human psychosexual differentiation.
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DOI 10.1007/s10508-009-9517-3
ORIGINAL PAPER
Peer Group Status of Gender Dysphoric Children: A Sociometric

Study
Madeleine S. C. Wallien Æ René Veenstra Æ
Baudewijntje P. C. Kreukels Æ Peggy T. Cohen-Kettenis
Received: 18 November 2008 / Revised: 7 May 2009 / Accepted: 24 June 2009 / Published online: 29 July 2009
The Author(s) 2009. This article is published with open access at Springerlink.com
Abstract In this sociometric study, we aimed to investigate classmates. In sum, at elementary school age, the relation-
the social position of gender-referred children in a natural- ships of gender dysphoric children with opposite-sex chil-
istic environment. We used a peer nomination technique to dren appeared to be better than with same-sex children. The
examine their social position in the class and we specifically social position of gender-referred boys was less favorable
examined bullying and victimization of gender dysphoric than that of gender-referred girls. However, the gender-re-
children. A total of 28 children (14 boys and 14 girls), referred ferred children were not more often bullied than other chil-
to a gender identity clinic, and their classmates (n = 495) dren, despite their gender nonconforming behavior.
were included (M age, 10.5 years). Results showed that the
gender-referred children had a peer network of children of the Keywords Gender identity disorder Gender dysphoria
opposite sex. Gender-referred boys had more nominations on Children Victimization Peer relations
peer acceptance from female classmates and less from male
classmates as compared to other male classmates. Gender-re-
ferred girls were more accepted by male than by female Introduction
classmates and these girls had significantly more male friends
and less female friends. Male classmates rejected gender-re- Peer relations are important for children’s well-being, because
ferred boys more than other boys, whereas female classmates problems with peers in childhood may contribute to the genesis
did not reject the gender-referred girls. For bullying and of disorders (e.g., Hay, Payne, & Chadwick, 2004; Sourander
victimization, we did not find any significant differences et al., 2007). Peer relations in childhood are usually gender-
between the gender-referred boys and their male class- segmented (Maccoby, 1998). Same-sex peers are more liked
mates nor between the gender-referred girls and their female and less disliked than other-sex peers (Dijkstra, Lindenberg, &
Veenstra, 2007). Most children prefer same-sex friendships and
their interactions are often characterized by gender-related
qualities, including patterns of sex-typed play and social inter-
M. S. C. Wallien B. P. C. Kreukels P. T. Cohen-Kettenis (&) action styles (e.g., Maccoby & Jacklin, 1987). In general, chil-
Department of Medical Psychology, VU University Medical
dren consider same-sex friendships and play styles more ac-
Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
e-mail: [email protected] ceptable than being friends with children of the other sex or
having a play style of the other sex. Moreover, there is evidence
M. S. C. Wallien B. P. C. Kreukels P. T. Cohen-Kettenis that children react negatively to atypical gender behavior of
Neuroscience Campus Amsterdam, VU University Medical
other children (Carter & McCloskey, 1984; Levy, Taylor, &
Center, Amsterdam, The Netherlands
Gelman, 1995; Ruble et al., 2007; Signorella, Bigler, & Liben,
R. Veenstra 1993; Smetana, 1986; Stoddart & Turiel, 1985).
Department of Sociology, University of Groningen, Groningen, Children with gender identity disorder (GID) experience
The Netherlands
feelings of belonging to the other sex, a strong cross-gender
R. Veenstra identification, and a persistent discomfort with their biological
Department of Psychology, University of Turku, Turku, Finland sex or the gender role associated with their sex. Children with
123
554 Arch Sex Behav (2010) 39:553–560
GID usually prefer playmates and toys of the opposite sex and conclusions of Zucker et al. (1997). These studies imply that,
they also have their play styles. There are a number of studies according to their parents, children showing gender atypical
that have examined whether gender-referred children showed behaviors function worse socially than their peers. However,
more cross-gender behaviors and feelings than non-referred parents are not always fully aware of what happens in their
children (e.g., Fridell, Owen-Anderson, Johnson, Bradley, & child’s social environment and, therefore, it is possible that
Zucker, 2006; Johnson et al., 2004; Cohen-Kettenis, Wallien, parental measurements do not provide a complete or accurate
Johnson, Owen-Anderson, Bradley, & Zucker, 2006; for an picture.
overview, see Zucker & Bradley, 1995). Fridell et al. (2006) In one observational study (Fridell, 2001), it was examined
compared the preferences for playmates and play styles in whether non-referred boys and girls liked to play with gender-
gender-referred children (199 boys, 43 girls) with those of referred boys. Fridell created age-matched experimental play-
controls (96 boys, 38 girls): The gender-referred children groups consisting of a gender-referred boy and two non-referred
significantly preferred other-sex playmates and cross-sex play boys and two non-referred girls (age range, 3–8 years). After
styles. In studies of Johnson et al. (2004), using a parent ques- two play sessions, conducted a week apart, each child had to
tionnaire, and Wallien et al. (in press), using a semi-structured select their favorite playmate from the group. Non-referred boys
child interview, gender-referred children showed significantly and girls chose most often other non-referred children, indi-
more gender atypical behaviors and cross-gender feelings than cating a distinct preference over the gender-referred boy.
the children in the control groups. Bates, Bentler, and Thompson (1979) used parental report
Because children with GID show extreme gender atypical to assess the number of male and female playmates of so-called
behavior, it is often assumed that they have a deviant social gender-deviant, normal, and clinical control boys. Boys with
position, poor peer relations, and are victimized by peers. gender problems had more female playmates than clinical
Green (1976) conducted a longitudinal study involving four control boys and less male playmates than normal and clinical
groups of children: Feminine boys, non-feminine boys, mas- control boys.
culine girls, and non-masculine girls. He conducted clinical In the current study, we extended these previous methods by
interviews with the children and used parental descriptions of examining sociometric data from the naturalistic environment
the boys’ or girls’ behaviors. The feminine boys appeared to (the school classroom) to investigate the social position of
relate best to same-age girls and next best to older girls, gender-referred children. We included both boys and girls re-
whereas the masculine boys related best to boys of all ages. ferred to our clinic because of gender dysphoria. We used a peer
Moreover, the feminine boys were more often rejected by nomination technique to assess whether peers liked or disliked
their peers or withdrawn than the masculine boys. Green, their gender atypical classmates and whether they bullied them
Williams, and Goodman (1982) reported on maternal ratings or were victimized by them (Veenstra et al., 2007).
of peer group relations of the four groups. The non-feminine Victimization was studied because normative studies have
boys and the non-masculine girls were more likely to have shown that peer relations are important for children’s well-
good same-sex peer group relations than the feminine boys being and that childhood victimization has long-term negative
and the masculine girls. The feminine boys had poorer same- consequences (e.g., Bond, Carlin, Thomas, Rubin, & Patton,
sex relations than the masculine girls. 2001; Kumpulainen & Räsänen, 2000; Sourander et al., 2007).
Zucker, Bradley, and Sanikhani (1997) constructed a Peer It has even been argued that, in children with GID, like in
Relations Scale from the Child Behavior Checklist (CBCL; homosexual or bisexual people, it is related to co-morbid
Achenbach, 1991) and obtained CBCL data of 275 gender- psychiatric disorders (Carbone, 2008; Green, 1987), probably
referred children and their siblings. The Peer Relation Scale through a mechanism involving minority stress (Meyer, 2003).
consisted of three items: ‘‘Does not get along with other kids,’’ Bullying often takes place at school (Olweus, 1993) and is
‘‘Gets teased a lot,’’ and ‘‘Not liked by other kids’’ (internal more frequent among boys than girls (e.g., Boulton & Under-
consistency was .81). They showed that, according to their wood, 1992). Furthermore, boys are more negatively judged
parents, gender-referred children (both boys and girls) had when showing gender atypical behaviors than are girls (Antill,
significantly poorer peer relations than their siblings, and the Cotton, Russell, & Goodnow, 1996; Zucker & Bradley, 1995)
gender-referred boys tended to have poorer peer relations than and boys are more negative about gender norm violations than
the gender-referred girls. However, the Peer Relations Scale girls (Blakemore, 2003; Killen & Stangor, 2001; Zucker, Wils-
reported by Zucker et al. (1997) did not specify the sex of the on-Smith, Kurita, & Stern, 1995). Gay or bisexual males in
children’s peers. Possibly, parents would report differences for middle or late adolescence reported to have been victimized
the items as a function of the sex of the peers, i.e., Gets teased a mostly by other males, whereas lesbians or bisexual females
lot by boys or Gets teased a lot by girls. A subsequent CBCL were victimized nearly equally by males and females (D’Aug-
study by Cohen-Kettenis, Owen, Kaijser, Bradley, and Zucker elli, Grossman, & Starks, 2006).
(2003) on data of 358 Canadian gender-referred children and We expected that the gender-referred children would be
130 Dutch gender-referred children was in line with the more rejected by same-sex peers and more accepted by oppo-
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Arch Sex Behav (2010) 39:553–560 555
site-sex peers as compared to non-referred children. We ex- mission to contact the school of their child. If they gave
pected that, in our study, the gender-referred boys would be permission, we sent a letter to the school of the child explain-
more accepted by female than by male classmates, and more ing the study. If the school wanted to participate, a research
rejected and victimized by male than by female classmates. assistant visited the school of the gender-referred child. The
For gender-referred girls, we expected that they would be consent of the controls to participate in the study was under
more accepted by male than by female classmates, but vic- jurisdiction of the school.
timized by both male and female classmates (though less so The peer-nomination data were collected during school
than the gender-referred boys). Finally, we expected gender- hours, from October 2005 to March 2007. Children complet-
referred girls to be more accepted by same-sex peers than ed the questionnaires in the school class, under the supervi-
gender-referred boys. sion of a research assistant. Before the research assistant
visited the school, the first author called the teacher to make
an appointment. She asked teachers not to mention the gender
Method dysphoric child when explaining the procedure to the chil-
dren. All children (our patients included) were thus unaware
Participants of the target child. Furthermore, the name of the target child
was not given to the research assistant; thus, the assistant was
The group of gender-referred children was solicited from a also unaware of the target child.
cohort of children age 7 years or older referred to the Gender
Identity Clinic of the Department of Medical Psychology of Measures
the VU University Medical Center (VUmc) in Amsterdam
between 2004 and 2006. The Ethical Committee of the VUmc Peer Acceptance and Rejection
approved the study.
Of the 44 referred children, 28 children (14 boys and 14 Children were asked to nominate their classmates on a range
girls) and all their classmates participated in this study. All re- of behaviors. The number of nominations they could make
ferred children had clear cross-gender preferences and iden- was unlimited (they were not required to nominate anyone)
tified with the other sex (8 of the boys and 7 of the girls had a and same-sex as well as other-sex nominations were allowed.
GID diagnosis, 6 of the boys and 7 of the girls were subthresh- The numbers of nominations children received individually
old for GID). from their same- and other-sex classmates with regard to
Sixteen of the 44 children did not take part in the study ‘‘best friends’’ and ‘‘dislike’’ were used to create measures of
because their parents did not give permission to contact the same- and other-sex peer acceptance and peer rejection. After
school (n = 4) or because the school refused to participate the numbers of received nominations had been summed,
(n = 12). The group of non-participants consisted of 9 girls - proportions were calculated to take differences in the number
(7 with a GID diagnosis, 2 were subthreshold for GID) and 7 of respondents per class into account, yielding scores from 0
boys (3 with a GID diagnosis and 4 were subthreshold for to 1 (see Veenstra et al., 2007 for more information on this
GID). The mean age of the participating gender-referred dyadic peer nomination procedure).
children was 10.47 years (SD = 1.27; range, 8.11–12.77).
Ninety-seven percent of the classmates participated in the Bullying and Victimization
study. The sample yielded 523 children from 27 elementary
school classes (23 regular and 4 special education): 232 girls The term bullying was defined to the students in the way for-
(44.4%) and 291 boys (55.6%), with a mean age of 10.59 years mulated in the Olweus’ Bully/Victim questionnaire (Olweus,
(SD = 1.32). The mean class size was 19.4 children (SD = 1996), which emphasizes the repetitive nature of bullying and
4.4). Schools were situated in both rural and (sub-)urban areas. the power imbalance between the bully and the victim. Several
The percentage of children with parents with a low educational examples covering different forms of bullying were given. It
level, at maximum a certificate of secondary vocational edu- was also stated that bullying can take place on the Internet or
cation, was 16.9%. The percentage of children from ethnic via text messages. Moreover, an explanation of what did not
minorities (of whom at least one parent was born outside the constitute bullying (e.g., teasing in a friendly and playful way;
Netherlands) was 18.7%. fighting between children of equal strength) was also given.
The numbers of nominations children received individually
Procedure from their same- and other-sex classmates with regard to dif-
ferent forms of bullying and victimization were used to create
At the first clinical session of the gender-referred child with measures of same- and other-sex bullying and victimization.
the family, parents or caregivers received a letter in which the We asked ‘‘who do you bully?’’ and ‘‘by whom are you bul-
purpose of the study was explained. Parents were asked per- lied?’’, using five forms of bullying and victimization: (1) taking
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556 Arch Sex Behav (2010) 39:553–560
things; (2) hitting, kicking, or pinching; (3) throwing things; (4) group (gender-referred versus control children). For boys, the
calling names or laughing; (5) excluding or ignoring. A sample overall MANOVA, F(15, 275) = 8.34, p \ .001, indicated that
item was ‘‘which classmates do you bully by taking things from gender-referred boys differed from the other boys in their social
them?’’ There were no clear differences in the association of the position. It appeared that gender-referred boys had more nom-
different forms of bullying and victimization with peer status. inations on peer acceptance from female classmates, and less
For that reason, we combined the different forms in highly from male classmates as compared to other male classmates (see
reliable scales for bullying and victimization (internal consis- Peer acceptance scale Table 1, column 2 and 3).
tency: .89 and .87, respectively). For peer rejection, male classmates nominated gender-re-
For control children, bullying towards boys correlated .50 ferred boys significantly more often than other male classmates
(p \ .01) with bullying towards girls. Being victimized by as someone they disliked, and female classmates nominated the
boys correlated .39 (p \ .01) with victimization by girls. The gender-referred boys significantly less often than other male
correlation of bullying towards and being victimized by same- classmates as disliked. For prosociality, gender-referred boys
sex classmates was .61 (p \ .01) for boys and .48 (p \ .01) for differed from their male classmates: Gender-referred boys were
girls (see also Table 2). more often considered helpful by female classmates than their
male classmates. For bullying and victimization, we did not find
any significant differences between the gender-referred boys
Prosociality and their male classmates.
Most gender-referred boys received at least one best friend
The number of nominations children received from their nomination from male classmates (92.9%). However, gender-
classmates with regard to four prosociality items was used to referred boys (92.9%) had more often at least one best friend
create a measure of prosociality. The peer nomination items among girls than their male classmates (56.3%), z(289) = 2.46,
were: Which classmates ‘‘… invite you to play (e.g., for a p \ .05.
game)?’’, ‘‘…share things with you (e.g., when they have Of the gender-referred boys, 78.6% received at least one
something delicious)?’’, ‘‘…help you when you are sad?’’, and dislike nomination by their male classmates compared with
‘‘…help you with school assignments?’’ The internal consis- 54.9% of their male classmates, z(289) = 1.49, ns. In contrast,
tency of the scale was .82. For control children, prosociality 57.1% of the gender-referred boys received at least one dislike
towards boys correlated -.35 (p \ .01) with prosociality to- nomination of their female classmates compared to 77.3% of
wards girls. their male classmates, z(289) = -1.39, ns.
Statistical Analysis Gender-Referred Girls Versus Other Girls
Multivariate analyses of variance were used to ascertain dif- For girls, the overall MANOVA, F(15, 216) = 4.91, p \ .001,
ferences between nominations of the gender dysphoric chil- indicated that gender-referred girls differed from the other girls
dren and their classmates and to examine the differences be- in their social position. Gender-referred girls were more ac-
tween the received nominations for each sex separately. cepted by male than by female classmates. These girls had sig-
nificantly more male friends and less female friends (see Ta-
ble 1, column 5 and 6). For peer rejection, we found that male
classmates rejected the gender-referred girls less than they re-
Results jected other girls. However, female classmates did not reject
gender-referred girls significantly more than other girls. In
Gender-Referred Children Versus all Other Children addition, gender-referred girls were considered more helpful by
male classmates and less helpful by female classmates com-
In general, the overall mean rate of nominations of the gender- pared to other girls. For bullying and victimization, we did not
referred children did not differ from the mean rate of the other find any significant differences between the gender-referred
children on peer acceptance, peer rejection, prosociality, and girls and their female classmates.
bullying and victimization scale. The overall MANOVA was A significantly higher percentage of the gender-referred
F(15, 507) \ 1. girls (92.9%) received at least one best friend nomination
from their male classmates compared with their other female
classmates (61%), z(230) = 2.12, p \ .05. The proportion of
Gender-Referred Boys Versus Other Boys gender-referred girls that received at least one best friend
nomination from their female classmates (71.4%) differed sig-
Table 1 shows the differences in Peer acceptance, Peer rejec- nificantly from the proportion of their female classmates that
tion, Prosociality, Bullying and Victimization as a function of received at least one best friend nomination (95%), z(230) =
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Arch Sex Behav (2010) 39:553–560 557
Table 1 Mean nominations and significant differences on Peer acceptance, Peer rejection, Prosociality, Bullying, and Victimization between the
gender-referred children (GR) and their classmates
Variable Boys Girls
GR Controls GR Controls
(N = 14) (N = 277) (N = 14) (N = 218)
M SD M SD M SD M SD
Peer acceptance
Boys .17 .13 .39 .20 t(289) = -6.05, g2 = .05** .32 .14 .11 .12 t(230) = 6.09, g2 = .15**
2
Girls .44 .29 .12 .16 t(289) = 3.96, g = .15** .25 .27 .47 .25 t(230) = -3.21, g2 = .05**
Combined .27 .14 .27 .14 .29 .09 .27 .13
Peer rejection
Boys .22 .21 .12 .15 t(289) = 2.67, g2 = .03** .07 .09 .16 .18 t(230) = -3.34, g2 = .02**
2
Girls .12 .15 .27 .25 t(289) = -3.29, g = .02** .13 .19 .09 .14
Combined .17 .11 .18 .16 .09 .08 .13 .14
Prosociality
Boys .23 .12 .33 .16 t(289) = -2.20, g2 = .03* .29 .15 .15 .13 t(230) = 3.67, g2 = .06**
Girls .41 .21 .11 .11 t(289) = 5.31, g2 = .24** .27 .21 .47 .20 t(230) = -3.73, g2 = .06**
Combined .30 .14 .23 .10 .28 .11 .29 .12
Bullying
Boys .06 .07 .07 .08 .04 .05 .03 .05
Girls .06 .08 .06 .09 .06 .06 .04 .05
Combined .06 .06 .07 .08 .05 .04 .04 .04
Victimization
Boys .05 .06 .04 .07 .02 .04 .03 .06
Girls .03 .05 .02 .05 .03 .04 .02 .05
Combined .04 .04 .04 .05 .02 .03 .03 .05
** p \ .01; * p \ .05
-2.98, p \ .01. Fifty percent of the gender-referred girls re- Correlations Between Dependent Variables
ceived at least one dislike nomination from their male class-
mates compared to 64.2% of their female classmates, Table 2 shows the correlations between study variables for
z(230) = -0.77, p = .44. Of the gender-referred girls, 42.9% gender-referred and control children. It turns out that the cor-
had at least one same-sex dislike nomination compared to relations are quite similar for gender-referred and control chil-
45.4% of their female classmates, z(230) = -0.13, ns. dren, with some notable exceptions: Among control children,
Table 2 Correlations between study variables for gender-referred and control children
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
1. Peer acceptance by boys – -.38* -.35* .03 .77* -.38* .00 -.23 -.23 -.16
2. Peer acceptance by girls -.33* – .24 -.34* -.10 .61* -.03 .05 .17 -.21
3. Peer rejection by boys -.40* -.06 – -.01 -.25 .16 .57* .00 .47* -.03
4. Peer rejection by girls .14* -.49* .28* – .16 -.32* -.04 .43* -.03 .37*
5. Prosociality by boys .78* -.26* -.39* .09* – -.08 .09 .04 -.04 -.04
6. Prosociality by girls -.46* .86* -.01 -.49* -.35* – .16 .05 .08 .07
7. Bullying toward boys .02 -.18* .47* .40* .00 -.17* – .35* .68* .05
8. Bullying toward girls .04 -.21* .22* .48* .04 -.18* .50* – .53* .53*
9. Victimization by boys -.15* -.12* .55* .35* -.11* -.11* .61* .31* – .17
10. Victimization by girls -.09* -.15* .35* .37* -.09* -.08* .27* .48* .39* –
Note: Correlations for GID children (N = 28) above and for control children (N = 495) below the diagonal. * p \ .05; * p \ .10
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558 Arch Sex Behav (2010) 39:553–560
bullying toward boys was related to rejection by girls rejected by male peers than their male classmates. From some
(r = .40), whereas it was unrelated for gender-referred chil- CBCL studies (Cohen-Kettenis et al., 2003; Zucker et al.,
dren (-.04). This difference is significant, z = 2.26, p = .02. 1997), it was concluded that gender-referred children gen-
Victimization by boys was for control children related to erally have poor relationships. This notion should be adjusted
rejection by girls (r = .35), whereas it was unrelated for as our study shows that it apparently only holds for same-sex
gender-referred children (-.03). This difference is marginally relationships. Gender-referred children do appear to have
significant, z = 1.93, p = .054. Victimization by girls was for other relationships than their peers (that is with other-sex
control children related to rejection by boys (r = .35), whereas peers), which are not necessarily poor. The findings of the
it was unrelated for gender-referred children (-.03). This earlier studies might be explained by a misinterpretation of
difference is marginally significant, z = 1.93, p = .054. the parents of their child’s relations. Because GID children
have few or no same-sex friends, parents may interpret this as
poor peer relations, even though the children may be satisfied
Discussion with their other-sex relationships.
An explanation for the acceptance of gender dysphoric
In this study, we examined the social position of gender children might be that children usually stay in the same group
dysphoric children and whether these children were bullied at during elementary education. This makes that the classmates
school. The social position of the gender-referred children of the gender dysphoric children were familiar with them for
varied as a function of the sex of their classmates. Gender- such a long time that personal experiences with the child
referred boys were more accepted by female classmates than might have overridden more general expectations, beliefs,
by male classmates and more rejected by male than by female and negative attitudes regarding gender variance (Martin,
classmates. Gender-referred girls were more accepted by Fabes, Evans, & Wyman, 1999). Unfortunately, we do not
male classmates than by female classmates and more rejected have the information to test this explanation.
by female than by male classmates. Also, most rates on homophobic bullying so far were based
Comparing the gender-referred boys to male classmates on self-reports of adolescents or adults. It is possible that ado-
and the referred girls to female classmates, our results were in lescents treat gender nonconforming behavior differently than
line with Green’s studies (Green, 1976; Green et al., 1982) of children, because in early adolescence other-sex friendships
maternal reports on peer-group relations of feminine boys begin to emerge (Feiring, 1999; Shrum, Cheek, & Hunter,
and masculine girls. Both gender dysphoric boys and girls 1988) and their social networks become more mixed (Poulin &
had peer networks of children of the opposite sex. That is, the Penderson, 2007). Features that underlie attraction to same- and
ratings of the gender-referred children were the mirror image other-sex peers change from childhood to early adolescence
of the male and female classmates’ ratings. Male classmates (Bukowski, Sippola, & Newcomb, 2000). Likewise, features
accepted other male classmates more than the gender-referred that underlie rejection and bullying might change when chil-
boys, and female classmates accepted the gender-referred dren transition from elementary school to high school. Retro-
boys more than other male classmates. For referred girls, we spective reports on bullying from adults and adolescents may
found that male classmates accepted these girls more than have reflected high school experiences rather than elementary
other female classmates, whereas female classmates accepted school experiences.
other female classmates more than the gender-referred girls.
Furthermore, the gender-referred children apparently showed Strengths and Limitations
more prosocial behavior towards opposite sex than same-sex
peers. A strength of this study was that we have investigated a sample
We did not find that gender-referred children were more of 28 gender-referred children and all their classmates. Infor-
often bullied than the other children. We found, however, in mation on gender-referred children usually stems from parent
agreement with normative studies (e.g., Fagot, 1977; Lang- or self-reports. In our study, classmates of gender-referred
lois & Downs, 1980) and the study of Green (1976), that the children provided information on peer relations, prosociality,
referred boys experienced more negative social consequ- bullying, and victimization. It is likely that the classmates gave
ences of their gender nonconforming behaviors than the re- a more complete and accurate picture than parents or gender-
ferred girls. Female classmates did not reject the gender referred children themselves do, especially because the
dysphoric girls, whereas gender dysphoric boys were clearly classmates were unaware of the true nature of the study.
rejected by other boys. Gender-referred boys might thus A limitation was that our sample of gender-referred children
experience more problems in their contact with same-sex was relatively small. However, smaller samples often occur in
peers, at least during the elementary school years. research among referred populations having rare conditions.
Although gender-referred children were accepted by With our sample size, we could still detect differences between
opposite-sex classmates, the gender-referred boys were more gender-referred boys and girls and their same-sex classmates at
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Arch Sex Behav (2010) 39:553–560 559
the level of 2% explained variance. Thus, our sample appeared and bisexual youth. Journal of Interpersonal Violence, 21, 1462–
to be large enough to find differences with a small effect size. 1476.
Dijkstra, J. K., Lindenberg, S., & Veenstra, R. (2007). Same-gender and
In sum, our study showed that, at elementary school age, cross-gender peer acceptance and peer rejection and their relation
the relationships of gender dysphoric children with opposite- to bullying and helping among preadolescents: Comparing
sex children are indeed better than with same-sex children. predictions from gender-homophily and goal-framing approaches.
The position of gender-referred girls seemed to be relatively Developmental Psychology, 43, 1377–1389.
Fagot, B. I. (1977). Consequences of moderate cross-gender behavior in
better than of gender-referred boys. However, in the 27 stud- preschool children. Child Development, 48, 902–907.
ied school classes in the Netherlands, the gender-referred Feiring, C. (1999). Other-sex friendships networks and the development
children were not more often bullied than other children, of romantic relationships in adolescence. Journal of Youth and
despite their gender nonconforming behavior. Adolescence, 23, 495–512.
Fridell, S. R. (2001). Sex-typed behavior and peer-relations in boys with
gender identity disorder. Unpublished doctoral dissertation, Uni-
Open Access This article is distributed under the terms of the Creative versity of Toronto.
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Green, R. (1976). One-hundred ten feminine and masculine boys:
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DOI 10.1007/s10508-009-9511-9
ORIGINAL PAPER
The Sexual Relationships of Sexual-Minority Women Partnered

with Trans Men: A Qualitative Study
Nicola R. Brown
Received: 9 February 2009 / Revised: 27 May 2009 / Accepted: 28 May 2009 / Published online: 16 July 2009
Abstract This qualitative research study examined the standing focus on male-to-female transsexuals (MTFs), who
experiences of sexual-minority women in romantic and sex- were thought to be many greater in number (Cromwell, 1999;
ual relationships with female-to-male transsexuals (N = 20) Devor, 1997a; Rubin, 2003). Drawing on my own research
using grounded theory analysis. This article reports data on and the existing literature, this article adds to this growing
issues related to sexual desire and practice in the context of a body of literature by examining issues of FTM partnership
partner’s transition, which participants said often compelled that have been largely overlooked. Despite the legitimate
a process of renegotiating bodies and sexual connection. interest in the partners of transsexuals, Huxley, Kenna, and
Participant reports on the influence of transition on the cou- Brandon (1981b) noted that researchers often have difficulty
ple’s sex life were mixed. Many participants discussed securing interviews with partners, whose perspectives are
changes in sex which were negatively affected in the course mostly missing from this body of work. Furthermore, the
of transition by a lesbian sexual orientation and a personal literature dedicated to women partners of trans men mostly
trauma history, and positively affected by a more embodied examines relationships that were formed post-transition and
partner and a partner with increased libido. More general with heterosexual women. This study addresses issues spe-
changes to the nature of their sexual life are detailed, cific to sexual desire and practice from the perspective of
including a greater dependence on heteronormative gendered the partners who, in this case, identify as non-heterosexual.
sexual scripts as transition began. It addresses these issues within the context of relationships
that were established as ‘‘same-sex’’ ones before a partner
Keywords Sexual relationships Sexual orientation disclosed being transsexual. In doing so, it addresses the
Female-to-male transsexuals Transsexualism experiences of an emergent population and adds to the
diversity of the literature.1
Lev (2004) argued that, historically, most of the relation-
Introduction ships transsexuals had were never expected to survive tran-
sition and that, similarly, within issues of partnership, a
Over the past three decades, there has been increasing schol- healthy and satisfying sexual relationship was not often as-
arly attention paid to female-to-male transsexuals (FTMs). sumed (Benjamin, 1977; Stoller, 1975). Some researchers
This greater attention has been due, in part, to their greater displayed open wonder at reports of sexual satisfaction by the
social visibility and attempts among some to correct a long- partners of transitioned transsexuals (Pauly, 1974; Steiner &
Bernstein, 1981). More current research articulates an appre-
ciation for the importance of partnerships and sexual satis-
N. R. Brown
Department of Psychology, York University, Toronto, ON, faction for trans people as quality-of-life measures and as
Canada
1
Cromwell (1999), Devor (1997a), and Rubin (2003) reported that a
N. R. Brown (&) significant number of FTMs have had ‘‘lesbian careers.’’ With the
Central Toronto Youth Service, 65 Wellesley St. East, increased visibility of, and available resources for, transsexual men,
3rd Floor, Toronto, ON M4Y 1G7, Canada more genetic females with significant gender conflicts who perhaps
e-mail: [email protected] previously mistook themselves for lesbians are deciding to transition.
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562 Arch Sex Behav (2010) 39:561–572
indicators of ‘‘success’’ in their post-transition lives (Law- practices were emphasized over sexual desire practices.
rence, 2005; Pfäfflin & Junge, 1992). A number of studies ex- Hines (2006) suggested that ‘‘the meanings and experiences
amining relationship and sexual satisfaction among female- of sexual identity and sexual desire and practice’’ (p. 368)
to-male transsexuals and their heterosexual female spouses shifted in relation to, and could sometimes adapt to, changes
described these relationships as satisfying and as qualitati- in gender identity. Similarly, Buxton (2006) observed that the
vely similar to comparison groups of nontranssexual hetero- minority of mixed-orientation relationships that continue do
sexual couples (Fleming, MacGowan, & Costos, 1985; Kin, so in different configurations, including ‘‘monogamy, open
Hoebeke, Heylens, Rubens, & De Cuypere, 2008). marriage, or closed loop (the GLBT spouse has a relationship
As this literature suggests, it is more common for stable with another married person of the same gender)’’ (p. 321).
partnerships to be formed post-transition (Lewins, 2002). Not all relationships that continue through transition retain a
There is evidence that transition can significantly stress exist- sexual element. Gurvich (1991) studied the impact femini-
ing relationships. Devor (1997a) reported that of the relation- zation had on the wives of MTFs. Although many wives
ships that FTMs had established with women pre-transition, continued to express feelings of love towards their partners,
approximately half of them did not survive transition. Partici- several of Gurvich’s interviewees said that they had lost
pants’ relationships ‘‘collapsed under the weight of their transsexual interest in their partners and had deliberately ended
sexual issues near the beginnings of their transitions’’ (p. 363). sexual contact.
Freedman, Tasker, and Di Ceglie’s (2002) study of families In examining how transition may affect the sexual desire
where a parent ‘‘came out’’ as transsexual (mostly MTF) and practice of sexual-minority women, Cook-Daniels (1998)
confirms the potential strain on partnerships. The majority of suggested that lesbian-identified partners of FTMs may
their parental sample was divorced or separated and the experience doubts about whether they will continue to find
clinical files of these couples recorded ‘‘a great deal of acri- their partners desirable. Nyamora (2004) noted that positive
mony between the parents’’ (p. 426). Gurvich’s (1991) study experiences of transition were associated with lesbians who
of heterosexual women whose ‘‘husbands’’ revealed identi- had greater flexibility in their sexual orientation. Further-
fying as MTF in the course of the marriage found that the more, Nyamora (2004) found that a more embodied trans
disclosure had a drastic and negative effect on their percep- partner (i.e., a partner who felt more connected to his body,
tions of the relationship as trustworthy and their expectations often associated with progression in transition) led to an in-
for a continued future with their partner. Buxton (2007) also crease in sexual intimacy, while women’s difficulties in inti-
found the disclosure of transsexuality for heterosexual spouses macy were, at times, associated with ‘‘their partner’s body
raised questions about the continuation of the marriage and issues; grief over the loss of a female partner; refusing to see
that most ended in separation within the first few years. Most their partner as a man and treating him like a woman’’ (p. 92).
of the transsexuals’ original marriages in Huxley, Kenna, and Lev (2004) offered that issues of ‘‘sexual desire and
Brandon’s (1981a) study of paired FTM transsexuals had compatibility’’ for partners of trans people are complex and
ended in separation or divorce. constitute more than simply bodies or preferences. Schleifer
Because few partnerships survive the transition, less is (2006) argued that ‘‘sexuality creates meaning about and
known about the ways in which transsexual transition affects through the sexed bodies and gendered identities of both
continuing partners and partnerships. The larger question of individuals involved in an erotic interaction’’ (p. 68). Hale’s
the potential challenges transition brings to a partner’s sexual (1995) work highlighted the importance of the couple com-
orientation is beyond the scope of this particular paper, re- mitting to a process of ‘‘recoding’’ bodies and sexual acts ‘‘to
sponses to which are detailed elsewhere (Alexander, 2003; produce an internally consistent [and understood] descriptive
Brown, 2009; Buxton, 2007; Cook-Daniels, 1998; Israel, truth’’ where ‘‘dominant cultural gender categorizations are
2005). It is acknowledged, however, that one’s sexual iden- …reorganized’’ (as cited in Cromwell, 1999, p. 134). Schrock
tity is a label which often represents an embodied practice of and Reid (2006) argued that this kind of recoding and reor-
desire and engagement of that desire, so they cannot be ganization constitutes part of the ‘‘identity work’’ task that
completely separated. trans people accomplish in establishing their gender identity.
Few researchers have examined specifically how transition This article does not revisit findings on sexual desire and
may affect the couple’s sexual relationship when the rela- practice from the perspective of trans men, which can be
tionship is established pre-disclosure and the couple remains found elsewhere (Cromwell, 1999; Devor, 1993, 1997a;
partnered. Hines (2006) investigated the issue of gender Dozier, 2005; Rubin, 2003). It merits noting, however, the
transition on relationships through the use of case studies and specific observation made in these studies that, as transition
found multiple potential relationship pathways and negotia- progresses and ‘‘sex characteristics become more congruent
tions in intimacy. Although not the predominant theme, in a with gender, behavior becomes more fluid and less important
sample narrative, a couple remained together through tran- in asserting gender’’ (Dozier, 2005, p. 297). This applies in
sition in a reconfigured partnership in which emotional care the sexual arena as well, where interviews with trans men
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Arch Sex Behav (2010) 39:561–572 563
suggest that their sexual practices with a partner may become data on the less considered sexual-minority women partners
more flexible as transition progresses. This finding is con- of trans men, and supports a growing trend of academic work
gruent with additional observations that trans men gener- that focuses on the importance of the body and embodiment
ally do not adhere to ‘‘rigid sex role stereotypes’’ (Fleming, with respect to gender and sexual identity (Cromwell, 1999;
MacGowan, & Salt, 1984, p. 56) and ‘‘carry out a relatively Dozier, 2005; Prosser, 1998; Rubin, 2003).
versatile erotic life’’ (Dulko, 1988, p. 171).
There is little research on the sexual orientation of female
partners of FTMs, making it difficult to establish what pro- Method
portion of partners this study sample may reflect. Many pre-
vious researchers have only used categories of ‘‘male’’ and Participants
‘‘female’’ partners because the question of investigation has
typically been to establish statistics on the sexual orientation The 20 participants were recruited through community con-
of FTMs themselves (e.g., Coleman, Bockting, & Gooren, tacts and local and international list-serves for partners of
1993; Lawrence, 2005). Chivers and Bailey (2000) found that, trans people. Inclusion criteria for the study were three-fold.
for FTMs attracted to women, both lesbian and heterosex- First, all participants had to be currently or once partnered
ual women were sexually appealing, with FTMs rating the with a female-bodied person who disclosed being transsexual
desirability of heterosexual women higher than for lesbian during the course of their relationship, which they had pre-
women. Lewins (2002) found that, of the six female partners viously understood to be a ‘‘same-sex’’ relationship. Second,
of FTMs in stable relationships, all of them identified as het- at the time of their partner’s ‘‘coming out,’’ all participants
erosexual. Huxley et al. (1981b) reported that, of nine FTMs, had to have self-identified as non-heterosexual. Third, par-
eight had female partners. The sexual orientation of these ticipants’ female-to-male partners had to have minimally
partners is not addressed, but five of them were living with an transitioned publicly in name and pronoun.2
FTM who had not yet had any SRS. This represents an unusual At the time of the interviews, 10 of the 20 participants were
departure from the assumption that many FTMs wait to form in active partnership with the FTM of whom they were speak-
relationships with women post-transition and suggests that at ing (relationship length varied from 1 to 9 years, with a
least some of these partners were involved with FTMs initially median of 4 years). Ten individuals discussed past relation-
as ‘‘women.’’ This would converge with the findings from ships (of a 1.5–5 year duration, with a median of 2.5 years).
Devor’s (1993) study of post-transition FTMs, in which 11 of
22 participants in long-term relationships with women had
partners who were with them ‘‘through transition’’ (p. 311). 2
Transsexuals are often motivated to pursue changes in order to bring
Only Steiner and Bernstein (1981) examined the previous his-
their physical bodies in line with their sense of gender. Rubin (2003)
tories of 21 women partners of FTMs in detail. Of their sample, argued that, for transsexuals, the notion of a core self is tied to the idea of
100% reported a previous relationship of more than 6 months ‘‘expressive errors’’ and ‘‘the belief that their bodies fail to express what
with a male and 95% reported previous intercourse with a they are inside is the central tenet legitimating their transitions’’ (p. 149).
In this way, transition is not simply about social recognition, but a means
male. Ten percent of the sample reported both a previous
‘‘to be recognizable to themselves’’ (Rubin, 2003, p. 151), that is, ‘‘a
relationship of more than 6 months and sex with a female. project in self-realization’’ (p. 152). The process of transitioning is
Interestingly, when asked about their preference of sexual complex, and can be open-ended or unfinished for years sometimes.
partners, 55% of the sample said their preference was for Transitioning can include a social and/or medical process. Social
transition may include a change in name, pronoun use, and presentation
males only, none had a preference for females only, while 45%
such as clothing, hair, and for FTMs, chest binding. Medical transition
said they had a preference for ‘‘either’’ males or females. may include hormone replacement therapy (for FTMs, testosterone),
Aggregating the numbers from these studies, of 56 partners, and some form of sex reassignment surgeries (for FTMs, including
30% identified as heterosexual, 36% as non-heterosexual, and bilateral mastectomy and chest contouring, hysterectomies, and/or
genital surgery of various forms such as metoidioplasty, phalloplasty, or
34% have to be classified as ‘‘unknown,’’ although likely the
scrotal implants). What constitutes ‘‘transition’’ and its completion is
majority of these partners were heterosexual in orientation. contested, and aside from legal definitions, may vary by individual. SRS
Sexual-minority women partners of FTMs are therefore a is difficult to access and is accompanied by high costs, which may be
relatively smaller subgroup of women partners of FTMs. prohibitive even when some aspects of it are covered by health plans.
Other reasons trans men may not pursue SRS include strong self-
Examining the experiences of partners of trans men adds
identification, a physical disability, religious prohibitions (Lev, 2004),
to a social scientific literature that has been identified by and/or dissatisfaction with the current sophistication of surgery
researchers as under-investigated. Despite the added sensi- (Cameron, 1996). Trans subjectivity (i.e., self-identification) can also
tivity in investigations related to sex and sexuality, this article exist independent of transition status. The inclusion criteria of the
research study are in no way meant to challenge the authenticity and
details partner accounts on these subjects in particular can-
legitimacy of trans identities independent of transition. Decisions
dor, and demonstrates both the sexual patterns and diversity around inclusion criteria were made in order to ensure a public role
that exists among these couples. In so doing, it contributes transformation that would have social implications for partners.
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564 Arch Sex Behav (2010) 39:561–572
Eleven of their partners had undergone some transition-re- questions within 48 h. All participants and the partners of
lated medical intervention(s), and most of the others were whom they spoke were given pseudonyms to protect their
actively planning to do so. Participants were Caucasian confidentiality.
(n = 14), South Asian, Black, and First Nations. One par- There were no differences in the amount and quality of
ticipant no longer identified as a woman, but as FTM himself. information obtained in telephone and in-person interviews,
Participants ranged in age from their mid 20s to 40s (median as has been found in other studies (Miller, 1991). The few
age, 31). Participant descriptions of their sexual orientation email interviews were substantially shorter and generally
shifted significantly in the course of their partner’s transition, lacked the same depth of information as the telephone and in-
although all retained a non-heterosexual identity. Pre-disclo- person interviews, even with follow-up questions. These
sure, 12 participants reported identifying primarily as lesbian, interviews were, however, useful in accessing the stories of
5 as queer, and 3 as bisexual. Post-disclosure and at the time more marginalized participants. One of these participants
of interview, 4 participants reported identifying primarily as was from the deaf community and preferred email over my
lesbian, 12 as queer, 2 as bisexual, and 2 as ‘‘open.’’ Three par- offer of paid ASL translation and another participant did sex
ticipants were actively parenting. All participants reported work as a primary means of income and made the request
that they had some post-secondary education. Reported class because her schedule was not conducive to a live interview.
status varied among participants, half of whom described The particular advantage of email interviews to include so-
themselves as being poor, low-income, working or criminal3 cially marginalized populations as well as the risks they carry
class, and half of whom identified themselves on a middle- in potentially producing a more ‘‘thin’’ interview relative to
class spectrum (see Table 1 for the social demographics of other methods (Mann & Stewart, 2000) were both true in this
participants). case. The decision to include these interviews in the sample
despite their limitations reflects the author’s valuing of hear-
Procedure ing from harder-to-reach participants.
Semi-structured interviews were conducted between Febru- Analysis

ary 2003 and April 2004. Interview questions covered three
major concepts: Disclosure of transsexuality, experiences Qualitative research is especially well-suited to new areas of
related to transition, and community support and affiliation. study (Flick, 1998) and allows researchers to build a ‘‘com-
Most relevant to the phenomenon of sexual desire and prac- plex, holistic picture…of a social or human problem’’ (Cre-
tice were the questions under the section of the interview swell, 1998, p. 15). Interview transcripts were analyzed using
related to transition. The interview explored ways in which grounded theory methodology, an inductive qualitative ap-
participants’ partners had decided to transition and partici- proach to generate theory from data (Strauss & Corbin, 1998).
pants’ levels of support for these decisions. Participants were In the analysis, text was divided into meaning units and the
asked whether there had been shifts in thinking or feeling units were subject to open coding. This coding was refined in
towards their partner’s transition over time and the nature of the context of the constant comparative method, the core
these shifts. Further questions related to ‘‘changes over time’’ analytic strategy. This strategy requires careful and repeated
included their relationship, their sexual identity, and sex with comparison of text and categories across transcripts, with a
their partner. focus on formulating and differentiating patterns in the data
Participants from Canada and the United States were (Strauss & Corbin, 1998). This process yields an explanatory
interviewed in person (11) or on the phone (6) or via email (3). model of a phenomenon (in this case, sexual desire and
In-person and phone interviews lasted from 75 min to over practice during a partner’s transition) and the identified fac-
2 h, with most interviews of approximately 2 h duration. tors that appear to account for the similarities and differences
All in-person and phone interviews were audio-recorded among participant experiences.
for transcribing purposes, transcribed by the author, and sent Unlike many other kinds of research, data collection and
back to participants for comments. The people who partici- analysis occur simultaneously. When themes begin emerging,
pated via email were sent the interview questions and re- participants are chosen with an eye to generating diversity
sponded to each question in a Word document that they then within the category, to test its inclusiveness and relevance
sent back to the researcher. These written responses were (i.e., ‘‘theoretical sampling’’). At the point at which new
read and participants were sent clarification and follow-up interviews did not add substantially to the current explanation
(Strauss & Corbin, 1998), the data are said to have reached
3
‘‘theoretical saturation’’ (Glaser & Strauss, 1967). Typical
Two of the interviewees made their primary income from sex work.
saturation estimates range from 12 (Lincoln & Guba, 1985) to
Participants denoted ‘‘criminal’’ to draw attention to the criminalization
of their labor from an institutional perspective, and to the particular 20–30 interviews (Creswell, 1998). The sample was kept to
stigma and risks their employment carried. 20 as no new themes of significance appeared at that point.
123
Table 1 Social demographics of participants
Pseudonym Age Relationship Relationship Stage of partner’s Sexual orientation Sexual orientation Education Social class
status at time duration medical transition prior to partner after partner transition
Arch Sex Behav (2010) 39:561–572
of interview (in years) transition
Aileen 30 With partner 8 HRT; chest surgery booked Dyke Queer University Middle class
Aisha 33 Not with partner 2.5 Non-testosterone masculinizing agent Queer bi dyke Queer bi dyke University Middle class
Amber 29 Not with partner 3 HRT Queer Queer University Working/criminal class
Ann 26 With partner 1.5 HRT Dyke Queer University Student
Cathy 46 With partner 6 HRT; chest surgery; hysterectomy Lesbian Open University Middle class
Cher 38 Not with partner 2 HRT Bidyke femme Bidyke femme University Middle class
Colin 31 Not with partner 2 None Queer Queer University Lower class
Collette 30 Not with partner 2 HRT; chest surgery Bi queer Bi queer University Middle class
Dido 27 Not with partner 3 None Gay Gay University ‘‘Struggling’’
Jamie 24 With partner 2 HRT Gay Gay High school Lower middle class
Jean 29 With partner 9 HRT; chest surgery booked Lesbian Queer University Paycheck to paycheck
Julie 37 With partner 4 HRT Lesbian Queer University Newly middle class
Lynn 33 Not with partner 5 None Lesbian Open University Lower class
Maria 29 With partner 5 HRT; chest surgery Bisexual Omnisexual University Student
Mistress 37 With partner 1 None Lesbian Queer lesbian University Middle class
Nicole 31 Not with partner 1.5 None Dyke Queer femme High school Working class
Sandi 28 With partner 6 None Queer bisexual dyke Queer bisexual dyke University Lower middle class
Sherisse 35 Not with partner 2 HRT Femme lesbian Queer femme University Working class
Serena 27 Not with partner 2.5 None Queer Queer University Working class
Tracey 29 With partner 4 HRT Lesbian Queer College Working class
565
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566 Arch Sex Behav (2010) 39:561–572
Results when he’s looking more of a man.’’ At the time of the inter-
view, Jamie was evaluating whether or not she could continue
The majority of participants reported that their partner’s the relationship. In the meantime, she and her partner had
transition compelled a process of renegotiating bodies and negotiated a non-monogamous relationship that would allow
sexual connection. Participant reports on the influence of Jamie to continue to have women as sexual partners.
transition on the couple’s sex life were mixed. A lesbian Another theme around the physicality of transition and its
sexual orientation and a trauma history were factors that impact on desire was a history of sexual abuse. Four of the
negatively affected the couple’s sex life, whereas a more participants in the study disclosed sexual abuse histories,
embodied partner or a partner with increased libido were brought to the forefront in new ways because of their part-
factors that positively affected the couple’s sex life. Some ners’ changing bodies on hormone replacement therapy (i.e.,
participants noted a bisexual or queer sexual identity and a testosterone). In this way, transition can raise fears and can
way of relating heterosexually to their FTM partner enhanced ‘‘trigger’’ traumatic memories of being abused, affecting sex-
the sexual relationship. Participants also reported more gen- ual relationships. These participants reported feeling increas-
eral changes to the nature of their sexual activities, including ingly unsafe and anxious as medical transition began, as well
the renaming of body parts, the introduction and loss of as experiencing visceral reactions to their partners’ masculin-
particular activities, and the possibility of similar activities izing bodies. Jean recalls:
changing in meaning through the process of transition.
When his body started becoming more masculine—the
smell of his sweat and getting body and facial hair—I
Factors Potentially Negatively Affecting Sexual Desire started being kind of afraid of his body…. I think my
and Practice in Couples history with men—I survived several rape/attempted
rapes in my teenage years—made me have a visceral
For 5 of the 12 lesbian-identified women whose partners were reaction to his changes. I think it wasn’t until I separated
actively medically transitioning to men, there was a fear that the person I have always known from the man that he
physical changes would negatively affect their sexual desire was becoming that I was okay with his transition.
for their partner. Said Dido, ‘‘I did question whether I would
Similarly, Julie said, ‘‘I guess I felt a little bit not safe at the
be able to still be sexually attracted to her as a male.’’ Ann also
beginning [of transition] and more vulnerable.’’ Her ‘‘survivor
spoke to sexual preference:
status’’ suddenly felt omnipresent and she feared that her
There are fears around arousal and how that’s going to lover was going to physically look more like the perpetrator.
work being a dyke (laughs)…. I’m more attracted to Like Jean, some women had returned memories of the abuse,
female bodies, so I love his breasts, he hates them…. and were worried that particular sensory experiences would
For lack of language, there’s a whole lot of grey area for trigger flashbacks (e.g., the feeling of facial hair). Some
where he may end up being comfortable with transition temporarily renegotiated sexual ‘‘ground rules’’ and estab-
and a certain amount of grey area that I consider with lished ‘‘signals’’ to slow down or stop sexual play to manage
my own sexuality and sexual orientation. I just hope triggers. In retrospect, some participants found the opportu-
that wherever these things rest, they’re compatible nity to work through this material a gift. On the other end of
because I’m not really bi[sexual]. I can be very com- Anne’s ‘‘terror’’, she felt ‘‘it was good’’ to unlearn some of the
fortable with the idea but there’s a certain point where beliefs she’d carried about men’s inherent dangerousness and
the reality of the body and what bodies tend to arouse ‘‘to realize as he’s transitioning how safe I still am with him.’’
me that could get difficult…. The relationship [hinges Not all participants with a trauma history felt threatened by
on] wanting to find a way where we can connect and not their partner transitioning. Amber provided a thoughtful
wanting to deny parts of myself. counternarrative of her survivor status with respect to trans
partners, whom she felt often had a deeper appreciation for
Similarly, Mistress anticipated there would be limits to the
open communication about sex and respect for sexual bound-
ways in which she could relate sexually to her transitioning
aries than many lesbians she knew:
partner on account of her sexual orientation being fundamen-
tally lesbian. She remembered a conversation early into When I am with someone who is trans, we have to talk
discussions about transition in which she expressed disinter- about sex. A trans man might need to tell me what is or
est in her partner obtaining phalloplasty: ‘‘Is that your goal? isn’t okay with touch and sex. He might not want to be
‘Cause really, unless it can go in a drawer, I ain’t feelin’ it, so I touched at all. Or he might want to stop or change what
don’t know, right?’’ Only one of these participants had a is happening in the middle of things. I get this. This
partner who had begun medical transition. Said Jamie, ‘‘His seems right and normal to me. I too have a need to
appearance [has changed]—it’s hard to be attracted to him discuss and negotiate. And most importantly, it has
123
Arch Sex Behav (2010) 39:561–572 567
never fazed a trans man when I have been triggered and Chris feels better about his body—he used to be really
needed to stop or change what we are doing. Trans disconnected from it and so sex was always [pause]
people don’t take sex for granted. This is paramount to when the moment came, I had to seize it (laughs), you
me. know? And now he’s feeling better about his body, he’ll
initiate sex. Like I just never knew where he was
coming from—if it was okay, or if it was not okay and
Factors Potentially Enhancing Sexual Desire and Practice
how he was feeling—it was a real point of tension be-
in Couples
tween us…so it became better that way.
More often than not, partners reported greater sexual access to Not all participant reports of partnered sex could easily be
their partners’ bodies and greater satisfaction with their sex categorized as ‘‘satisfying’’ or ‘‘unsatisfying.’’ Two women
life as transition progressed. Many trans people, particularly reported that there were some important aspects of their sex
pre-transition, have very difficult relationships to sex and life about which they felt positively, and other aspects about
their bodies, from which they often feel alienated or dis- which they felt ambivalent or dissatisfied. Cher, whose part-
identified (Devor, 1997a; Rubin, 2003). Fifteen participants ner had begun testosterone, had previously reported an in-
talked about pre-disclosure or pre-transition sex as being low crease in the frequency of sex, which she enjoyed. She felt
in frequency and/or access to his body being limited (e.g., uneasy, however, with changes in her partner’s apparent
trans partners remaining clothed during sex or common motivation for sex. She perceived his motivation to be increa-
erogenous zones being ‘‘off limits’’ to touch). Said Cathy, singly biological, and less about increasing connection with
‘‘Sex was complicated. It was almost non-existent. It was very her in particular as his partner.
furtive. It was very frustrating and long stretches in between
There’s a part of it that feels like it’s not about me…so
with nothing…’’ Serena described a pattern of initiating sex
I’m struggling with that. I’m assuming that [this will
and being rejected by her partner. ‘‘I think sexually, he had a
settle as his body adjusts to testosterone]…but there’s a
lot of shame around his body, and sexuality was something
part of [the way he approaches sex] that bugs me. It’s
that got pushed aside…[I didn’t feel] desired anymore….
not like, ‘‘Wow, I’m hot for you. I want to have sex with
Even though I knew it was about him—it still made me feel
you’’, it’s like, ‘‘I have this urge. I need to take care of
crappy about myself.’’ Teresa reported, ‘‘He would never take
it’’, you know? If I’m not there, he’s going to do
his shirt off [during sex], so there was a lot of body discomfort
something else, and if I am there, it’s like, ‘‘Do you want
stuff. There was no reciprocal touching at all and it was a little
to partake?’’ and it just doesn’t feel quite (laughs) like
crazy-making for me. I still wanted to touch him all the time
the kind of way I want to engage.
and I was trying to find the right way to do that.’’
A few participants reported their partner’s disclosure Teresa, whose partner had not begun medical transition,
initially increased their own discomfort and disrupted their enjoyed the sex she and her partner had, and yet felt constrai-
own sense of embodiment during sex. Dido said, ‘‘[His dis- ned in her own sexual expression:
closure] changed how comfortable I was sexually. I would
My options [in bed] were few (laughs). My option was to
avoid [certain body parts], but it was more conscious…there
totally enjoy being the one who was getting fucked the
was a lot of trepidation.’’ Lynn remembered, ‘‘If I touched her
whole time or not. It was incredibly enjoyable
breasts by mistake ‘cause I forgot—I just always had to be
[sex]…but there was a power dynamic. I wasn’t allowed
really careful that I didn’t remind her that she was female.’’
to initiate sex at all…. And it was exciting for him, but he
As 11 of the FTM partners underwent medical transition, 7
wanted to be in control of it…and that was crazy-making
participants noted significant and positive changes in sex, the
because the only things I could do to initiate [sex] was to
increased frequency of which they attributed to an increased
make myself seem sexy enough. I was just kind of doing
libido on testosterone, and the increased quality of which they
it [engaging sexually this way] because that’s what he
attributed to a more embodied partner. Since her partner
wanted, you know? But the sex was so good!
began testosterone, Cher noted, ‘‘His libido has way in-
creased…. He was not always as interested [in sex] and so Two participants, whose partners had not medically tran-
that’s been nice to have more sex than we’ve had before. I’m sitioned, relied on ‘‘good communication’’ and the creation
enjoying that.’’ Cathy reported that after her partner had chest of explicit and mutually fulfilling sexual roles to negotiate a
surgery, he was happier and more comfortable in his body, satisfying sex life. One of these women, Nicole, said she and
‘‘so there’s more access to his body now.’’ Julie said sex her partner created a more ‘‘embodied’’ sexual relationship,
‘‘kind of changed when he transitioned because he became namely through incorporating and sexualizing devices like a
more confident about his body, he had more enjoyment out of chest binder during intimacy. They also used sex as a cathar-
his sexuality and his body.’’ Aileen explained: tic experience for the stress of transition, wherein she thought
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568 Arch Sex Behav (2010) 39:561–572
of sex as ‘‘therapeutic’’ and herself as a ‘‘healer’’: ‘‘Sex be- became reorganized in relation to the trans person’s gender and
came an important area to be able to deal with all the emotions sexual activities appeared to become increasingly gendered.
of [social] transition.’’ Another participant, Mistress, said There was the introduction of, or increased emphasis on,
that despite suddenly finding herself, a Black lesbian, in an activities meant to confirm or bolster a partner’s masculinity
unlikely relationship with a ‘‘straight white man’’, her partner and thelossofotheractivitiesthatcouldbeseentoundermineit.
helped her ‘‘come home’’ to herself as a femme and a sexual Colin had a unique story in the participant pool. Once a queer
‘‘top’’ in mutually-encouraged journeys of greater authenti- woman partner of an FTM, watching his partner begin to tran-
city: sitionmadehimrealizehetoowasatransman,andsoheoffereda
dual perspective in the study. He shared from his perspective as
It was like [being] a kid in a candy store, it truly, truly,
now FTM, ‘‘There’s a fair bit of reclaiming that has to go along
truly was, and it’s really kind of shifted out of this space
with words [during sex]. Second of all, that reclamation has to be
of being bottom, bottom, bottom, bottom, bottom,
usedbythepartnerwho’sthere….I’vegottofeellikemyidentity
bottom, to really exploring dominance, and so it’s been
as a guy is being respected.’’ A number of participants described
liberating and powerful.
a renaming of a partner’s body parts; ‘‘dick’’ instead of ‘‘clit’’,
Five participants felt that their previous sexual and ‘‘chest’’ instead of ‘‘breast.’’ Accordingly, Cher talked about
romantic experience with biological men bolstered their changes in sexual practice to reflect this renaming. ‘‘How I then
partner’s sexual confidence and helped consolidate and/or go down on him is also different, right?’’ Cher said oral sex
affirm his gender identity. Reflecting on the trans men she had shifted to best approximate ‘‘a blow job.’’
dated, Amber said, ‘‘They are into the idea that I sleep with Said Collette:
biological males. I think it makes me less like a lesbian, which
they don’t want to feel like.’’ Maria shared: We reoriented sexually. We just somehow sensed and
started to respond to each other a little differently. It was
I just kind of treated him like a boy and actually always like a recalibration at every stage, you know? By the time
felt like he was a boy. I was much more used to dating we broke up, our sex was nothing like what it was when
boys than girls anyways, so I knew how to be the girl- we started. It was great, wonderful sex and it was just
friend of a boyfriend, in ways that I didn’t really know new with every month, but to be honest, it only got better.
how to be the girlfriend of a girlfriend—so that really
worked for him because it made him feel like a boy, Not every participant found there was an easy synchronicity.
which is what he needed. Since her partner began testosterone, Tracey noted:
Similarly, Aisha reported: [David’s] sex drive has just increased by 300%—I have
to bat him off me in the middle of the night (both
[One of the things that] was important to him was that laugh)…but at the same time…physically, things are
because I had dated more men than women, I was very changing so it’s like, a little bit, sometimes I can just
heterosexual in the way that I am in a relationship and so have fun with that and kind of discover new things and,
I treated him—well, I mean at that point it wasn’t clear other times, it’s just a little bit discouraging and upset-
that he was supposed to be a him, but I’m saying that ting because things are shifting and I just—sometimes, I
now—I treated him like a boy the way I treated all my don’t know what my role is anymore. I don’t know how
other boyfriends and so I think that the relationship else to put that and I don’t know the things I’ve always
made transitioning [more real for him]. known, you know? Like that one thing that’s always
It is noteworthy that at times these same men who felt guaranteed to work sort of thing. I mean just little things
bolstered by their partner’s sexual histories with men also felt like that, and his body’s different now, it’s like—it’s just
threatened by them. One participant described this threat a whole new body to get used to and then, sometimes I
expressed in jealousy of her friendships with heterosexual can just forget all about it and it’s wonderful, you know?
men. For another participant whose income came from sex Numerous participants noted an increased focus on part-
work, this threat was expressed in her partner’s anger that she ners penetrating them and, sometimes, a loss of interest in
slept with biological men who were able to engage in activ- previously enjoyed activities. Ann laughed at how much ‘‘my
ities (i.e., penetrating her) that he could not. dildo became his cock.’’ Lynn said sex shifted so there was
‘‘more of an emphasis on using dildos…he’d want to wear
Changes in the Nature of Sexual Activity more all the time.’’ Jamie said,
It was not unusual for participants to report the nature of their I truly miss…the way we had sex. Sex is good just
sexual activity changing, including the renaming of body parts, sometimes his way of fucking me is like a man and it’s
and the emphasis on particular activities shifting. Sex largely hard to be turned on. He no longer likes penetration and
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Arch Sex Behav (2010) 39:561–572 569
me touching his chest. There’s a certain way to satisfy patterned aspects appear largely related to: a trauma history,
him and it’s frustrating on my part because it’s limited for degree of flexibility in participant sexual orientation, degree
me. I want to explore and do more, but I can’t with him. of partner body dysphoria, and stage of the partner’s transi-
tion. Overall, sex seemed to be more limited in the early
Cher’s partner also began feeling ambivalent about being
stages of transition, and became more varied and satisfying as
penetrated by her, which Cher partially attributed to myths
transition progressed. Sex during transition appeared to be a
circulating that ‘‘if you become a trans guy you shouldn’t love
dynamic process, evidenced in partner reports of an ongoing
your cunt anymore’’ and his concerns that particular activities
‘‘reorienting’’ to bodies and practice, and the possibility of
undermined how his masculinity would be perceived by her.
same practices to change in meaning.
Cher said, ‘‘I would miss that, so I’m nervous about that.’’
The finding that some women with trauma histories experi-
Itwasalsoevident thatsimilar sexualpracticescouldchange
enced post-traumatic reactions to their partner’s medical tran-
in meaning for either partner as transition progressed. Ann
sition is, as far as I know, a novel finding. It refutes an earlier
highlighted this phenomenon in her description of her partner
hypothesis made by Steiner and Bernstein (1981), who sug-
for whom using a harness and dildo for penetration was iden-
gested that transsexual men may be a ‘‘safe compromise’’ for
tity-affirming at first, and at another point in time, identity-
women with traumatic histories as ‘‘protection against further
disaffirming (i.e., a reminder of the physical limitations of his
pregnancies or a defence against involvement with biological
body as it was, and the sense of inadequacy this brought).
males with whom they have had unsatisfactory emotional [or
Similarly, Colin said that when he was first transitioning, he
traumatic] experiences in the past’’ (p. 181). Steiner and Bern-
wentthroughaperiodofnotwantingpenetrativesexbecausehe
stein’s hypothesis appears to assume that women do not take
felt ‘‘like that was somehow not appropriate’’ for his male
their partners as fully male. Clearly, being with a trans man did
gender identity, but as he became increasingly secure in his
notallowparticipantstoside-steptraumaticmaterial.Indeed,the
identity as a gay trans man, and as long as his partner was clear
appreciation of theirpartners as male,and anticipatingand/or the
on the meaning of the activity as a form of anal sex, he could
beginning of his medical transition, provoked post-traumatic
participate enjoyably. Sherisse added, ‘‘I’ve since been with
responses. If sexual-minority women have partners thinking
trans guys where [I could penetrate them] and I’ve also been
aboutorabouttotransition,andthey haveatraumahistory,thisis
with trans guys where touching their breasts was fine.’’
an area where pro-active work in anticipating traumatic resur-
Sometimes that sex carried the weight of a partner’s
facing would be helpful, as a number of participants described
gender identity issues took an emotional toll on participants.
these feelings coming as a surprise to them, and feeling unpre-
During a period of ‘‘burn out’’ doing sex work as her primary
paredinmanagingthem.Ifthefemalepartnerissuccessfullyable
means of income, Amber recalled:
to manage the triggers that arise, it is likely a factor that only
I felt that in the bedroom I had to be über-sexy, über- temporarily negatively affects the sexual relationship.
positive, and try to be bigger than Li’s gender issues. I Sexual orientation, sexual desire, and physiological arou-
wasn’t in the right head space. I felt tired and weak. I sal are connected. A lesbian identification was associated
wanted to be treated like a fragile person. I wanted with greater difficulties in arousal and doubts about whether
acknowledgement that my sexuality was complicated the relationship would continue, whereas a bisexual, queer, or
too. Li and I never worked this out. He felt rejected and even lesbian identity that contained some amount of flexi-
defensive. bility was more compatible with a transitioning partner.
These findings support Cook-Daniels’ (1998) report of a con-
Along side the changes many participants observed, some
cern among lesbian-identified women of whether they would
interviewees maintained their sexual life had actually chan-
continue to find their transitioning partners desirable. These
ged quite little post-disclosure and during medical transition.
findings also fit Nyamora’s (2004) conclusion that greater
Jean felt, ‘‘Actually, [sex] hasn’t changed at all.’’ Julie also
flexibility in sexual orientation was associated with positive
reported, ‘‘In terms of the activities in our sex life, it was very
experiences of transition. Partners may deeply wish to con-
similar.’’ Sandi’s partner was clear about ‘‘his boundaries and
tinue finding their partners desirable or imagine they will be
comfort when it came to sex’’ early on in their relationship,
able to navigate transition at its outset. It appears that the start
and Sandi said she felt ‘‘fine’’ about his preferences.
of a partner’s medical transition is a critical time and a test of
the embodied reality for whether or not their wishes can be
borne out in continued practice. Israel (2005) found that for
Discussion partners who are set in their orientation, ‘‘often the point of
the person starting hormone treatments signals the end to the
Participant experiences with partnered sex during transition, relationship’’ (p. 62).
particularly the degree of change in sexual practice and/or its Stage of transition, then, is a significant factor in changes
flexibility/rigidity, are affected by various factors. These to partnered sex. Stage of transition is also related to changes
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570 Arch Sex Behav (2010) 39:561–572
in a partner’s libido, where the beginning of testosterone was language denies the capacity for sexual-minority women to
associated with greater frequency in sex. This finding sup- regard their partner as male and assumes a fixed nature of
ports research indicating increased libido as one of the more women’s sexual desires and trajectories that other research
substantiated links to androgens (Cohen-Kettenis & Gooren, has brought into question (Diamond, 2008).
1992). Stage of transition was also related to the partner’s Schrock and Reid (2006) argued that part of the ‘‘identity
level of body dysphoria and the degree of identity affirma- work’’ task that trans people accomplish involves accounting
tion/security he had. Increased masculinization was associ- for their sexual pasts and constructing a coherent narrative
ated with less body dysphoria and greater embodiment, that supports or bolsters their gender identity. This task is
which participants reported increased the quantity, and less made more complex for trans men who transition but stay
predictably the quality, of sex. This supports Nyamora’s with their female partners in what began as a ‘‘same sex’’
(2004) finding that greater embodiment in a trans partner was relationship—both they and their partners have identity
associated with a more positive experience of transition work to accomplish, individually and in relationship with one
among queer women partners. another. This may be a helpful concept to understand the
Participant reports confirm the existing literature on chan- sexual experiences of queer women partners, some of whom
ges to sexual relationships during transition from the per- are asked to draw on their heterosexual histories in new ways,
spective of trans men (e.g., Devor 1997a, b; Dozier 2005). For and participate in more gendered sexual scripts. Besides
trans men early in transition, their masculinity may be more being a means for trans men to affirm their gender identity and
easily injured or threatened as they establish their identities. sexuality, it may also be an individual strategy for trans men
There were generally more restrictive sexual activities early to distance themselves from what is ‘‘lesbian’’ or ‘‘queer.’’
in a transition, with an increased focus on stereotypical Devor (1997b) reported that while a lesbian identity may
gendered practices (e.g., men penetrating their partners, a have been an initial ‘‘testing ground’’ for sex and gender for
wish for female partners to be more passive during sex). A his FTM participants with ‘‘lesbian’’ pasts, it was ultimately
few participants reported this time as one in which they felt recognizing significant differences in experience and feeling
frustrated and inhibited by new or continued restrictions that helped them clarify that they were ‘‘not lesbian’’ but
during sex. As in Nyamora’s (2004) study, partners of trans transsexual. The most striking of these differences was a dis-
men can experience grief reactions in the loss of sex as it used identification with their female bodies and a disinterest in
to be. More often than not though, sex before transition was sexual partners relating to them, or trying to pleasure them, as
more limited and so changes through transition were often for females. Devor argued that the identity development trajec-
the better. Although Buxton (2006) suggested that the frame- tory for these FTMs does involve a process of dis-identifi-
work of mixed-orientation relationships may be reconfigured cation from what is lesbian.
to include other sexual partners, only one relationship in this Marked changes in sexual practices may also be a non-
sample became non-monogamous as a relationship strategy explicit relational strategy to facilitate an ongoing partner’s
to remain together. As the confidence of trans partners grew cognitive shift to fully appreciate her partner as male. These
and the body dysphoria lessened, there was some evidence shifts are also influenced by larger cultural understandings of
that there was increasing flexibility in sexual activities and heterosexuality, and community understandings of ‘‘authen-
boundaries. As transition progressed, there was a trend to- tic’’ identities among trans men, as implied by Colin’s story
wards greater participant satisfaction with sex and greater and Cher’s reference to ‘‘myths’’ that circulate in peer groups.
access to their partner’s body. An ‘‘identity work’’ framework also explains why, as a male
Participant reports about changes in language referencing identity consolidates and strengthens for both partners, var-
the body to affirm and respect their partners’ gender, as well iation in sexual repertoire may be introduced when its shared
as changes in relating sexually to their partner as male, reflect meaning is assured.
the importance of sex as co-constructed in its meaning, as
Schleifer (2006) and Hale (1995) both argued. Participants Limitations of the Research
Dido and Lynn, who continued to use female pronouns in
reference to their partners, were no longer with these partners. Sex is often considered a private matter between partners and
It seems likely that partners of transitioning people must is a sensitive research topic. All participants addressed the
accept their partner’s gender, and not simply shift their sexual issue of sex and many participants were candid in their ac-
behaviors, if the relationship is to survive. In this regard, counts of changes to their sexual relationships related to their
some researchers have made overgeneralizations about sex- partner’s transition. When asked, two participants, Dido and
ual-minority women. Chivers and Bailey (2000) conclude Sandi, spoke vaguely and/or peripherally about sex. Con-
from FTMs’ higher ratings of ‘‘heterosexual’’ versus ‘‘les- versational analysis studies have revealed that the normative
bian’’ women as sexually desirable, a preference for partners English conversational rules are such that people rarely di-
‘‘who thus regard their FTM partner as male’’ (p. 272). This rectly refuse a question or say ‘‘no’’ (Kitzinger & Frith, 1999,
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Arch Sex Behav (2010) 39:561–572 571
as cited in Gavey, 2005). I thus took these minimal responses often related to relationship endings. A related question is
as refusals and did not push for further information. It may or how duration of relationships prior to transition may affect
may not be that these women had sexual experiences with relationship outcome. Does a longer ‘‘same-sex’’ relation-
their partners that would have changed the emerging patterns. ship tend to last through transition or does the longevity of the
Another limitation of the study was that many of the par- ‘‘same-sex’’ identity work against the continuation of the
ticipants were younger in age and perhaps as a by-product of relationship? Another area of study would be to locate wo-
this skew, most relationships were also of limited longevity. men who now identify as heterosexual, and compare their
Interviewing partners in more long-standing relationships experiences to a sample such as this. Continued work with
would have elicited greater perspective of how sex evolves non-clinical samples is encouraged on account of the forth-
‘‘over time’’ in transition. The majority of participants were coming nature of such interviews and the complexity they
Caucasian and the homogeneity of the sample in this regard hold.
limits a comprehensive analysis of how race may shape the
sexual experiences of partners. Acknowledgements This author wishes to gratefully acknowledge
Dr. Sandra Pyke as her past advisor and to thank Dr. Aaron Devor and the
Furthermore, because of a convenience sample, the results reviewers and the Editor for their helpful feedback on the article. This
of this study may have limited generalizability to other research was generously supported, in part, by a doctoral SSHRC grant.
FTMs’ female partners through transition. In particular, a
proportion of 50% may be an under-representation of women
partners who leave these relationships and may be difficult to References
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DOI 10.1007/s10508-008-9420-3
ORIGINAL PAPER
Societal Individualism Predicts Prevalence of Nonhomosexual

Orientation in Male-to-Female Transsexualism
Anne A. Lawrence
Received: 27 November 2007 / Revised: 3 July 2008 / Accepted: 5 September 2008 / Published online: 9 December 2008
Abstract There are two distinct subtypes of male-to- approved transgender roles for pervasively feminine homo-
female (MtF) transsexuals: homosexual and nonhomosex- sexual gender dysphoric men, are plausible contributors.
ual. The relative prevalence of these two subtypes varies
dramatically between countries, but no explanation of this Keywords Individualism Collectivism Transsexualism
variability has yet been proposed. This study examined the Sexual orientation Gender dysphoria
hypothesis that the prevalence of nonhomosexual MtF
transsexualism, relative to homosexual MtF transsexualism,
would be higher in individualistic countries than in collec- Introduction
tivistic countries. I analyzed data from 22 studies of MtF
transsexualism, conducted in 16 countries, examining the It is now widely accepted that there are two distinctly dif-
association between percentage of nonhomosexual partici- ferent types of gender dysphoric men who request or undergo
pants and Hofstede’s (Culture’s consequences: Comparing sex reassignment (Blanchard, 1988; Buhrich & McConaghy,
values, behaviors, institutions, and organizations across 1978; Freund, Steiner, & Chan, 1982; Levine, Gruenewald,
nations, 2001) Individualism Index (IDV). IDV accounted & Shaiova, 1976; Money & Gaskin, 1970–1971; Smith, van
for 77% of observed variance in the percentage of nonho- Goozen, Kuiper, & Cohen-Kettenis, 2005). One type consists
mosexual MtF participants (r = 0.88, p \ .0001). Control- of men who are usually extremely feminine in their behavior
ling for differences in national wealth and in Hofstede’s other and appearance and who are exclusively sexually attracted to
indices of societal values (Power Distance, Uncertainty men, an erotic interest called androphilia. These individuals
Avoidance, and Masculinity) did not significantly change the are usually referred to as homosexual male-to-female (MtF)
ability of IDV to account for variance in the percentage of transsexuals. The other type consists of men who are less
nonhomosexual participants. The factors that contribute to feminine in their behavior and appearance and who may be
the observed association between societal individualism and sexually attracted to women (an erotic interest called gyne-
the relative prevalence of nonhomosexual MtF transsexual- philia), to women and men, or to persons of neither sex, but
ism remain to be determined, but a greater tolerance within who also almost always have a history of sexual attraction to
individualistic countries for socially disruptive gender tran- the idea of being women, an erotic interest called autogyne-
sitions by nonhomosexual gender dysphoric men, and the philia (‘‘love of oneself as a woman’’; Blanchard, 1989a, b,
availability within many collectivistic countries of socially 2005). These latter individuals are usually referred to as
nonhomosexual MtF transsexuals.
The relative prevalence of homosexual versus nonhomo-
A. A. Lawrence sexual MtF transsexualism appears to differ dramatically in
Department of Psychology, University of Lethbridge, Eastern versus Western countries. Studies conducted in
Lethbridge, AB, Canada Korea (Kim et al., 2006), Malaysia (Teh, 2001), Singapore
(Tsoi, 1990), and Thailand (Winter, 2006), for example, have
A. A. Lawrence (&)
6801 28th Ave. NE, Seattle, WA 98115, USA found that fewer than 5% of MtF transsexuals studied were
e-mail: [email protected] nonhomosexual. Many studies conducted in the United
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574 Arch Sex Behav (2010) 39:573–583
Kingdom (e.g., Green & Young, 2001; Muirhead-Allwood, better accepted, and would occur more commonly, in indi-
Royle, & Young, 1999) and the United States (e.g., Law- vidualistic countries than in collectivistic countries. I also
rence, 2005; Schroder & Carroll, 1999), in contrast, have hypothesize, for reasons I will explain, that gender transition
found that 75% or more of the MtF transsexuals studied were by homosexual gender dysphoric men probably would occur
nonhomosexual. No explanation of these cross-cultural dif- no less commonly, and perhaps more commonly, in collec-
ferences in the relative prevalence of homosexual and non- tivistic countries than in individualistic countries. Taken to-
homosexual MtF transsexualism, however, has yet been gether, these ideas suggest the hypothesis that the prevalence
proposed. of nonhomosexual MtF transsexualism, relative to homo-
The extent to which national cultures emphasize individ- sexual MtF transsexualism, will be higher in individualistic
ualism, or its theoretical opposite, collectivism, may be an countries than in collectivistic countries. What specific ob-
important factor in explaining differences in the relative servations and arguments support these hypotheses?
prevalence of the two MtF transsexual types. Hofstede (2001) First, consider nonhomosexual gender dysphoric men
provided the following definitions of individualism and who request or undergo MtF sex reassignment: Probably a
collectivism: few nonhomosexual men in every country will experience
gender dysphoria and will consider sex reassignment, but the
Individualism stands for a society in which the ties
extent to which they will openly request or actually undergo
between individuals are loose: Everyone is expected to
sex reassignment is likely to vary, based on societal attitudes
look after himself/herself and her/his immediate family
and values. Gender transition by nonhomosexual men has the
only. Collectivism stands for a society in which people
potential to be socially disruptive, because these men are
from birth onwards are integrated into strong, cohesive
often married (Lawrence, 2005; Muirhead-Allwood et al.,
in-groups, which throughout people’s lifetime continue
1999), frequently have children (Blanchard, Clemmensen, &
to protect them in exchange for unquestioning loyalty.
Steiner, 1987; Lawrence, 2005; Muirhead-Allwood et al.,
(p. 225)
1999), and often hold established positions in their societies,
Some relevant differences between individualistic and especially if they undergo sex reassignment in their 40s or
collectivistic national cultures, as described by Hofstede, 50s (not an uncommon phenomenon in Western countries;
are summarized in Table 1. Yet another significant differ- Lawrence, 2005). Moreover, the physical appearance of
ence between individualistic and collectivistic societies is nonhomosexual gender dysphoric men is less convincingly
wealth: Individualistic countries tend to be wealthier than feminine than that of homosexual gender dysphoric men
collectivistic ones, and gross national income per capita (Smith et al., 2005), which might make it more difficult for
(GNI/capita), a standard measure of societal wealth, is the former to blend smoothly into society following gender
strongly correlated with measures of societal individualism transition. In countries where individualism is a dominant
(Hofstede, 2001). value and individual self-expression is encouraged or at least
Given these differences between individualistic and col- tolerated, nonhomosexual gender dysphoric men probably
lectivistic countries, I hypothesize that gender transition by would be more likely to openly express or actualize their
nonhomosexual gender dysphoric men probably would be cross-gender desires, up to and including undergoing sex
Table 1 Differences between individualistic and collectivistic national cultures

Individualistic cultures Collectivistic cultures
‘‘I’’ consciousness ‘‘We’’ consciousness

Self-orientation Collectivity orientation
Identity is based in the individual Identity is based in the social system
Everyone has a right to a private life Private life is invaded by institutions and organizations to which one belongs
Hedonism Survival
Autonomy, variety, pleasure, individual financial security Expertise, order, duty, security provided by organization or clan
Weak family ties, rare contacts Strong family ties, frequent contacts
More divorces Fewer divorces
Privacy is normal Nobody is ever alone
Less conformity behavior More conformity behavior
Self-concept idiocentric Self-concept in terms of group
Self-supporting lifestyles Other-dependent lifestyles
Note: From Hofstede (2001, pp. 227, 236, 237, 245)
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Arch Sex Behav (2010) 39:573–583 575
reassignment, because any resulting social disruption would Traditionally, when cross-dressing males are reason-
more probably be considered an excusable consequence of ably masculine in their gender roles and largely heter-
individual self-expression. In countries where collectivism is oerotic in their orientation, they have been diagnosed as
a dominant value and individual self-expression is discour- transvestites. When they are either effeminate and
aged or denigrated, however, nonhomosexual gender dys- homoerotic, or masculine appearing and homoerotic—
phoric men probably would be less likely to openly express that is, whenever they are clearly homoerotic—their
their cross-gender desires by undergoing sex reassignment, cross-dressing has never been diagnosed in any of the
because this type of socially disruptive self-expression would DSM nosologies. This inconsistency—the influence of
probably be considered undesirable, if not inexcusable. orientation on the diagnosis of cross-dressing—con-
A study by Blanchard (1994) supports the idea that feel- tains a message: the culture understands that cross-
ings of social obligation influence the expression of cross- dressing reflects a deep, abiding wish to be a female.
gender wishes in nonhomosexual gender dysphoric men, This is far more shocking when it occurs among
even in individualistic national cultures. In a study conducted seemingly masculine heterosexuals—’’real men’’—
in Canada, an individualistic country, Blanchard found that, than among homoerotic males. We in the mental health
among nonhomosexual gender dysphoric men, fatherhood establishment tend to diagnose that which is shocking.
and marriage were associated with delays of about 2 and Many people intuitively grasp a relationship between
4 years, respectively, in requests to undergo sex reassign- homoeroticism and the persistent intense, but trans-
ment. The nonhomosexual gender dysphoric men Blanchard formed childhood wish to be female. (p. 134)
studied usually attributed these delays to feelings of obliga-
As Levine suggests, the desire of nonhomosexual men to
tion toward their families. It seems plausible that nonhomo-
resemble or become women is usually regarded as shocking
sexual gender dysphoric men living in collectivistic countries
and unacceptable, whereas the desire of homosexual men to
might not only delay seeking sex reassignment, but might
resemble or become women is often considered unremark-
often forego sex reassignment altogether, based on feelings
able. This suggests that gender transition by homosexual men
of obligation to their families.
will often be regarded as more socially acceptable than
Second, consider homosexual gender dysphoric men:
gender transition by nonhomosexual men.
There is good reason to believe that gender transition by
As previously noted, collectivistic societies place a high
homosexual gender dysphoric men probably would occur no
value on inclusion; perhaps for this reason, many collectiv-
less commonly, and perhaps more commonly, in collectiv-
istic countries provide socially approved transgender roles
istic countries than in individualistic countries. Gender
into which men who display pervasive (not merely episodic)
transition by homosexual men may create relatively little
cross-gender attitudes and behaviors may transition. Such
familial or social disruption, because homosexual men who
men are almost always exclusively homosexual (Teh, 2005;
seek sex reassignment rarely marry women or father children
Whitam, 1987, 1997; Winter, 2006). Examples of such so-
in individualistic countries (Bentler 1976; Blanchard et al.,
cially approved transgender roles include the bayot in the
1987; Lawrence, 2005), and almost never do so in collec-
Philippines (Whitam, 1997), the hijras in India (Nanda,
tivistic countries (Tsoi, 1990). Moreover, in individualistic
1994), the kathoey in Thailand (Winter, 2006), the mak nyahs
countries, homosexual men who seek sex reassignment are
in Malaysia (Teh, 2005), and the waria in Indonesia (Whitam,
likely to do so at younger ages than nonhomosexual men
1997). Individualistic societies, in contrast, are less concerned
(Lawrence, 2005; Smith et al., 2005), usually by their late
about inclusion, and few, if any, individualistic countries
20s. In collectivistic countries, homosexual men who un-
provide socially approved transgender roles into which men
dergo sex reassignment or begin living as women often do so
who display pervasive cross-gender attitudes and behaviors
in their teens or early 20s (Kim et al., 2006; Tsoi, 1990;
may transition. Consequently, gender transition by homo-
Winter, 2006). Homosexual men this young are unlikely to
sexual men who display pervasive cross-gender attitudes and
hold positions of responsibility or influence in their societies.
behaviors will probably occur at least as often, if not more
Consequently, it is probably much less socially disruptive for
often, in collectivistic countries than in individualistic ones.
homosexual men to seek or undergo sex reassignment than
Additionally, there is evidence that extreme gender-vari-
for nonhomosexual men to do so, and this may be especially
ance tends to be more common among homosexual men
true in collectivistic countries. As a result, collectivistic
living in collectivistic countries than among homosexual
countries may have little incentive to actively discourage
men living in individualistic countries. This implies that the
gender transition by homosexual men, even if they do not
percentage of homosexual men who might seriously consider
officially condone or encourage it.
undergoing sex reassignment is likely to be larger in collec-
Levine’s (1993) description of differing societal attitudes
tivistic countries than in individualistic countries. Whitam
toward cross-dressing and cross-gender expression by
(1987) observed that, in countries such as the United States
homosexual and nonhomosexual men is also relevant here:
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576 Arch Sex Behav (2010) 39:573–583
and the United Kingdom (both highly individualistic), only than in collectivistic countries. Taken together, these prop-
about 25% of homosexual men are markedly effeminate, ositions suggest the hypothesis that the prevalence of non-
whereas in countries such as the Philippines (highly collec- homosexual MtF transsexualism, relative to homosexual
tivistic), the percentage of markedly effeminate homosexual MtF transsexualism, will be higher in individualistic coun-
men is much greater, perhaps as high as 65%. tries than in collectivistic countries. To test this hypothesis, I
The factors that create these cross-cultural differences in examined contemporary studies of MtF transsexuals and
effeminacy among homosexual men are poorly understood. gender dysphoric men from a number of Eastern and Western
Lippa and Tan (2001) proposed that, in national cultures that countries that included information about the sexual orien-
are highly gender-polarized, including many collectivistic tation of study participants.
countries, gender roles are often inextricably linked to sexual
roles. In such cultures, men who are sexually attracted to
other men may strongly infer that they are therefore feminine, Method
and their attitudes and behaviors may reflect this inference. In
national cultures that are not highly gender-polarized, in- Studies of MtF transsexuals and gender dysphoric men were
cluding many individualistic countries, such an inference eligible for inclusion in the analysis if (1) the participants
of femininity by men who are attracted to other men may be either lived full-time as women, had completed sex reas-
less likely to occur, and the attitudes and behaviors of these signment surgery (SRS), or had been diagnosed with gender
men may tend to be less feminine. Lippa and Tan (2001) identity disorder (GID; American Psychiatric Association
examined gender-related traits in homosexual and hetero- [APA], 1994, 2000), transsexualism (APA, 1987; World
sexual men of Hispanic American, Asian American, and Health Organization, 1992), or gender dysphoria (APA,
White American ethnicity; heterosexual men displayed more 2000); (2) the study had been published or presented between
masculine scores than homosexual men across all ethnicities, 1988 and 2008; (3) the study contained information about the
but the difference was significantly greater among the His- participants’ sexual orientation, or a reasonable proxy for
panic American and Asian American participants, perhaps this; and (4) the study had been conducted in a country for
reflecting greater gender polarization and more collectivistic which the relevant measure of societal individualism versus
attitudes in Hispanic American and Asian American cultures. collectivism was available (see below). Studies that inten-
Finally, if gender transition by homosexual gender dys- tionally excluded persons with a nonhomosexual orientation
phoric men occurred less commonly—or no more com- (e.g., Rakic, Starcevic, Maric, & Kellin, 1996) or persons
monly—in collectivistic countries than in individualistic with some correlated attribute, such as marriage to a woman
ones, then this, combined with the hypothesized tendency of (e.g., Bower, 2001) were considered ineligible. When two or
collectivistic countries to discourage gender transition by more eligible studies from the same institution or team were
nonhomosexual gender dysphoric men to a greater extent available, and when the participant groups described in these
than individualistic countries, would lead to the expectation studies appeared to significantly overlap each other, only the
that the overall prevalence of MtF transsexualism would be latest or largest study was included. Potentially eligible
lower in collectivistic countries than in individualistic coun- studies were identified using the PubMed database (www.
tries. Just the opposite pattern has been observed, however: In pubmed.gov), the reference list from Pfäfflin and Junge’s
Singapore, the one collectivistic country for which reliable (1992/1998) review of SRS outcomes, tables of contents for
data are available, the prevalence of MtF transsexualism is volumes 1–10 of the International Journal of Transgender-
about 1 in 3000 postadolescent males (Tsoi, 1988). This is the ism, abstracts from the biennial symposia of the Harry Ben-
highest reported prevalence of MtF transsexualism in the jamin International Gender Dysphoria Association for the
world, much higher than in individualistic Western countries period 1997–2007, and the reference lists of any studies
such as Belgium (De Cuypere et al., 2007), the Netherlands identified using the previously listed sources. I sought to in-
(Bakker, van Kesteren, Gooren, & Bezemer, 1993), and clude studies from as many different countries as possible. I
Scotland (Wilson, Sharp, & Carr, 1999), in all of which the identified 22 eligible studies from 16 countries: Belgium (De
reported prevalence is about 1 in 12,000 postadolescent Cuypere, Jannes, & Rubens, 1995), Brazil (Petry et al. 2007),
males. Canada (Blanchard & Sheridan, 1992), Germany (Eicher,
In summary, then, there is reason to believe that gender Schmitt, & Bergner, 1991; Pfäfflin & Junge, 1990), Ireland
transition by homosexual gender dysphoric men probably (De Gascun, Kelly, Salter, Lucey, & O’Shea, 2006), Japan
would occur no less commonly, and perhaps more com- (Okabe et al., 2008), Korea (Kim et al., 2006), Malaysia (Teh,
monly, in collectivistic countries than in individualistic 2001), the Netherlands (Doorn, Poortinga, & Verschoor,
countries. There is also reason to believe that gender transi- 1994; Smith et al., 2005; Verschoor & Poortinga, 1988),
tion by nonhomosexual gender dysphoric men probably Singapore (Tsoi, 1990), Spain (Gómez-Gil, Trilla, Salamero,
would occur more commonly in individualistic countries Godás, & Valdés, in press), Sweden (Landén, Wålinder,
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Arch Sex Behav (2010) 39:573–583 577
Hambert, & Lundström, 1998), Switzerland (Rauchfleisch, studies that included information about self-reported sexual
Barth, & Battegay, 1998), Thailand (Winter, 2006), the orientation both before and after SRS (Lawrence, 2005;
United Kingdom (Green & Young, 2001; Muirhead-Allwood Muirhead-Allwood et al. 1999; Pfäfflin & Junge, 1990;
et al. 1999), and the United States (Lawrence, 2005; Rehman, Schroder & Carroll, 1999), participants were classified based
Lazer, Benet, Schaefer, & Melman, 1999; Schroder & on their orientation before SRS. In the study by Rehman et al.
Carroll, 1999). Data from these studies are summarized in (1999), some participants were described as have been mar-
Table 2. ried to women before SRS, which constitutes strong pre-
The eligible studies were diverse with respect to sample sumptive evidence of nonhomosexual orientation; these par-
size, definition of transsexualism or equivalent, and criteria ticipants were classified as nonhomosexual, regardless of
by which participants’ sexual orientation was defined. The their stated sexual orientation after SRS.2
participants included persons who had undergone SRS, per- The degree of societal individualism versus collectivism
sons diagnosed with transsexualism, GID, or gender dys- in the countries in which the studies were conducted was
phoria, and persons who lived full-time as women, with or assessed using Hofstede’s (2001) Individualism Index (IDV).
without a formal diagnosis. Most studies defined partici- The IDV was derived from factor analysis of the results from
pants’ sexual orientation in terms of self-reported attraction, over 116,000 paper-and-pencil surveys, completed in 1968
partner preference, or sexual experience; in two studies, and 1970 by employees of the IBM Corporation and its
sexual orientation reflected the overall judgment of treating subsidiaries in 72 countries. These surveys included, among
clinicians. For purposes of analysis, participants who were other items, many questions about cultural values. The range
sexually oriented exclusively toward men were classified as of possible IDV scores is 0–100. Countries with the highest
homosexual and participants who were sexually oriented IDV scores (highly individualistic) include the United States
toward women, women and men, or persons of neither sex (91), Australia (90), the United Kingdom (89), and Canada
were classified as nonhomosexual (Blanchard, 1988, 1989a, (80). Countries with the lowest IDV scores (highly collec-
b). For the study by Smith et al. (2005), participants’ self- tivistic) are found in Latin America and Asia: examples
reported sexual preference data were adjusted, per the include Guatemala (6), Ecuador (8), and Panama (11) in Latin
reanalysis by Lawrence (2008), to assign persons who re- America and Indonesia (14), Pakistan (14), and Taiwan (17)
ported sexual experience with female partners to the non- in Asia. The IDV has been extensively validated and dem-
homosexual group. For the study by De Gascun et al. (2006), onstrates good convergent validity (Hofstede, 2001).
which did not describe participants’ sexual orientation as Hofstede (2001) observed that societal wealth was strongly
such, a history of marriage to a woman was used to provided a correlated with individualistic attitudes. To address the pos-
minimum estimate of nonhomosexual orientation.1 sibility that any observed relationship between societal
MtF transsexuals who report a nonhomosexual orientation individualism and MtF transsexual typology might be med-
before SRS sometimes claim that their sexual orientation iated principally by differences in wealth between countries,
changed after SRS, resulting in exclusive sexual orientation for which individualism might simply be an incidental cor-
toward men (Lawrence, 2005). Because sexual orientation in relate, GNI/capita, as reported by the World Bank (2007),
adult males is usually considered to be immutable (Harry, was also explored as an alternative or supplemental predic-
1984; Pillard & Bailey, 1995; Swaab, 2007), these reported tor of differences in the relative prevalence of the two MtF
changes probably reflect increased autogynephilic sexual transsexual types.
interest in having sex as a woman with a man following SRS, Hofstede’s (2001) factor analysis of the IBM survey data
rather than a genuine change in somatotypic preference yielded, in addition to IDV, three other indices that described
(Blanchard, 1989b, 2005; Freund, 1985; Lawrence, 1999, differences in societal values between countries: (1) Power
2008; see also Lawrence, Latty, Chivers, & Bailey, 2005). Distance Index (PDI), measuring societal acceptance of in-
Consequently, classifying MtF transsexuals as homosexual equality; (2) Uncertainty Avoidance Index (UAI), measuring
versus nonhomosexual on the basis of self-reported sexual societal desire to avoid uncertainty about the future; and (3)
orientation after SRS may result in an overestimation of Masculinity Index (MAS), measuring societal achievement
homosexual orientation. To address this concern, in the orientation. These indices were also explored as alternative
or supplemental predictors of differences in the relative
1 prevalence of the two MtF transsexual types. Theoretically,
In studies of MtF transsexuals conducted in Western countries, the
percentage of participants who have been married to a woman is IDV, PDI, UAI, and MAS should be uncorrelated; in real-
typically 10–35 percentage points lower than the percentage of ity, Hofstede (2001) found that IDV and PDI displayed a
participants who have a nonhomosexual orientation (e.g., De Cuypere
et al., 1995: 45% married vs. 55% nonhomosexual; Lawrence, 2005:
2
67% vs. 91%; Muirhead-Allwood et al., 1999: 59% vs. 86%; Smith et al., MtF transsexuals whom clinicians would categorize as homosexual
2005, reanalyzed by Lawrence, 2008: 33% vs. 67%; Verschoor & almost never report having been married to women (Bentler, 1976;
Poortinga, 1988: 28% vs. 63%). Blanchard et al., 1987; Lawrence, 2005).
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578
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Table 2 Studies of male-to-female transsexualism included in the analysis
Study Country IDV PDI UAI MAS GNI/capitaa Diagnosis or status Nb % NHS Basis for deciding
sexual orientation
1. Blanchard and Sheridan (1992) Canada 80 39 55 53 36,170 Gender dysphoria 466 59 Clinician judgment
2. De Cuypere et al. (1995) Belgium 75 65 80 53 38,600 Transsexualism 22 55 Stated preference
3. De Gascun et al. (2006) Ireland 70 28 54 74 45,580 GID 45 38 Marriage to a woman
4. Doorn et al. (1994) Netherlands 80 38 45 14 42,670 Transsexualism 155 46 Imagined partner
5. Eicher et al. (1991) Germany 67 35 53 59 36,620 Completed SRS 40 33 Stated attraction
6. Gomez Gil et al. (in press) Spain 51 57 89 35 27,570 Transsexualism 157 9 Stated orientation
7. Green and Young (2001) UK 89 35 43 66 40,180 GID 443 76 Clinician judgment
8. Kim et al. (2006) Korea 18 60 85 39 17,690 GID 43 2 Stated attraction
9. Landén et al. (1998) Sweden 71 31 23 6 43,580 GID 120 42 Sexual experience
10. Lawrence (2005) USA 91 40 36 62 44,970 Completed SRS 227 91 Stated attraction
11. Muirhead-Allwood et al. (1999) UK 89 35 43 66 40,180 Completed SRS 133 86 Stated attraction
12. Okabe et al. (2008) Japan 46 54 112 87 38,410 GID 228 60 Stated attraction
13. Petry et al. (2007) Brazil 38 69 74 44 4,730 Completed SRS 21 0 Stated orientation
14. Pfäfflin and Junge (1990) Germany 67 35 53 59 36,620 Completed SRS 42 55 Sexual partnerships
15. Rauchfleisch et al. (1998) Switzerland 68 34 62 67 57,230 Completed SRS 13 38 Stated orientation
16. Rehman et al. (1999) USA 91 40 36 62 44,970 Completed SRS 28 46 Preference/marriagec
17. Schroder and Carroll (1999) USA 91 40 36 62 44,970 Completed SRS 17 76 Stated preference
18. Smith et al. (2005) Netherlands 80 38 45 14 42,670 GID 112 67 Preference/experienced
19. Teh (2001) Malaysia 26 104 36 50 5,490 Live as a woman 507 4 Stated attraction
20. Tsoi (1990) Singapore 20 74 31 52 29,320 Transsexualism 200 0 Stated attraction
21. Verschoor and Poortinga (1988) Netherlands 80 38 45 14 42,670 Transsexualism 135 63 Sexual experience
22. Winter (2006) Thailand 20 64 73 45 2,990 Live as a woman 195 2 Stated attraction
Notes: IDV = Individualism Index, PDI = Power Distance Index, UAI = Uncertainty Avoidance Index, MAS = Masculinity Index (all from Hofstede, 2001), NHS = nonhomosexual male-to-
female transsexuals, SRS = sex reassignment surgery, GID = Gender Identity Disorder. For studies in which participants had completed SRS, information about sexual orientation before SRS was
used when available
a
Gross national income per capita for 2006, in US dollars; from World Bank (2007)
b
Excludes participants for whom sexual orientation data were not provided
c
Stated preference data from this study were adjusted to assign persons who had been married to women to the nonhomosexual group
d
Stated preference data from this study were adjusted per reanalysis by Lawrence (2008) to assign persons with sexual experience with female partners to the nonhomosexual group
Arch Sex Behav (2010) 39:573–583
Arch Sex Behav (2010) 39:573–583 579
significant negative correlation, albeit one that became accounting for 79% of the observed variance in %NHS,
nonsignificant after controlling for GNI/capita. R2 = .79; R2 Adj = .77.
Bivariate correlations between IDV, PDI, UAI, MAS,
GNI/capita, and %NHS are shown in Table 3. As expected,
Results IDV was significantly correlated with PDI and GNI/capita, as
well as with %NHS. Also as expected, PDI, GNI/capita, and
Table 2 shows IDV, PDI, UAI, and MAS scores and GNI/ %NHS were significantly correlated with each other.
capita for the countries in which the studies were conducted, In a multiple regression analysis in which PDI, UAI, MAS,
along with the percentage of nonhomosexual MtF partici- and GNI/capita were included along with IDV as predictors
pants (%NHS) in each study. The relationship between IDV of %NHS, IDV was the only statistically significant predic-
and %NHS is displayed in Fig. 1. IDV and %NHS were tor, and the amount of variance explained was essentially
strongly correlated, r(22) = .88, p \ .0001, with IDV ac- unchanged, R2 = .80; R2 Adj = .73; these results are sum-
counting for 77% of the observed variance in %NHS, marized in the first column of Table 4. In a similar multiple
R2 = .77; R2 Adj = .76. This represents a large effect size regression analysis that excluded the eight studies involving
(Cohen, 1988). only participants who had undergone SRS, IDV again was the
To address the possibility that the association between the only statistically significant predictor of %NHS, and the
IDV and %NHS was attributable to principally to the inclu- amount of variance explained was again essentially un-
sion of studies involving persons who had undergone SRS, changed, R2 = .84; R2 Adj = .74; these results are summa-
the correlation was recalculated after excluding the eight rized in the second column of Table 4. These analyses
studies that involved only participants who had undergone demonstrate that the relationship between IDV and %NHS
SRS. The correlation between IDV and %NHS was essen- was not mediated simply by differences in national wealth,
tially unchanged, r(14) = .88, p \ .0001, with IDV now and that controlling for PDI, UAI, MAS, and GNI/capita did
Fig. 1 Percentage of
nonhomosexual MtF transsexual
participants (%NHS) versus
Hofstede’s Individualism Index
(IDV) for studies in Table 2
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580 Arch Sex Behav (2010) 39:573–583
Table 3 Bivariate correlations between independent and dependent Table 4 Multiple regression analyses for variables predicting per-
variables centage of nonhomosexual male-to-female transsexuals
PDI UAI MAS GNI/capita %NHS Variable b, all 22 studies b, 14 non-SRS studies
IDV -.76**** -.42 .04 .80**** .88**** IDV .88*** .87*

PDI .23 .00 -.79**** -.66*** PDI .06 .05
UAI .26 -.30 -.28 UAI .06 .10
MAS .11 .19 MAS .13 .15
GNI/capita .73*** GNI/capita .08 .14
Notes: IDV = Individualism Index, PDI = Power Distance Index, (R2 = .80; R2 Adj = .73) (R2 = .84; R2 Adj = .74)
UAI = Uncertainty Avoidance Index, MAS = Masculinity Index (all Notes: IDV = Individualism Index, PDI = Power Distance Index,
from Hofstede, 2001), GNI/capita = gross national income per capita UAI = Uncertainty Avoidance Index, MAS = Masculinity Index (all
for 2006 (from World Bank, 2007), NHS = nonhomosexual male-to- from Hofstede, 2001), GNI/capita = gross national income per capita
female transsexuals for 2006 (from World Bank, 2007)
*** p \ .001, **** p \ .0001 * p \ .05, *** p \ .001
not significantly affect the ability of IDV to account for

variance in %NHS.3 were excluded. IDV was not simply acting as a proxy for
national wealth, because controlling for GNI/capita did not
significantly affect the ability of IDV to account for variance
Discussion in %NHS. Controlling for Hofstede’s (2001) other indices of
societal values (PDI, UAI, and MAS) likewise did not sig-
The study’s hypothesis, that the prevalence of nonhomo- nificantly affect the ability of IDV to account for variance in
sexual MtF transsexualism, relative to homosexual MtF %NHS.
transsexualism, would be higher in individualistic countries One limitation of the analysis is the measure of societal
than in collectivistic countries, was strongly supported. The individualism used. In recent years, the assumption that
observed effect size was surprisingly large, given the widely individualism and collectivism define a bipolar scale—an
varying definitions of transsexualism employed in the studies assumption that is inherent in the IDV—has been critically
analyzed and the diverse criteria by which sexual orientation reexamined (Oyserman, Coon, & Kemmelmeier, 2002). At
was assessed. an individual level of analysis, individualism and collectiv-
The strong correlation between IDV and %NHS was not ism arguably are not polar opposites; at a societal level of
simply attributable to the inclusion of several studies that analysis, however, this is less clearly true (Dion & Dion,
involved only participants who had undergone SRS, because 2006). A more serious limitation of the IDV is that societal
a nearly identical correlation was observed when such studies individualism is unlikely to have remained unchanged over
the 40 years since Hofstede’s data collection began in 1968.
3 In fact, Hofstede observed an increase in individualism
A reviewer of an earlier version of this article proposed that I also
examine two putative measures of societal gender polarization, the among Japanese workers between his first data collection in
United Nations Development Programme’s (2005) Gender-related 1968 and his second in 1970. Consequently, the accuracy of
Development Index (GDI) and Gender Empowerment Measure (GEM), IDV as a measure of societal individualism has probably
as supplemental predictors of %NHS, based on Lippa and Tan’s (2001)
decreased over time for some countries. Nevertheless, IDV
suggestion that societal differences in gender polarization might affect
the likelihood that homosexual men will think of themselves as feminine continues to be widely used in cross-cultural research, partly
(and therefore possibly consider gender transition). This note briefly for lack of any equally comprehensive measure (Oyserman
summarizes the results of that analysis; further information is available et al., 2002). And, notwithstanding these concerns, the ob-
from the author.
served association between IDV and %NHS was remarkably
The GDI is a composite measure of male-female equality in life
expectancy, literacy, education, and earned income; the GEM is a strong.
composite measure of male-female equality in political power, high- Another limitation of the analysis is that the participants in
status professions, and earned income. GDI figures are available for all the studies analyzed were unlikely to have constituted rep-
countries in the present study except Singapore; GEM figures are
resentative samples of MtF transsexuals in the countries in
available for all except Brazil (United Nations Development Pro-
gramme, 2005). For the countries in the present study, the most relevant which the studies were conducted. For example, in countries
bivariate correlations were: GDI and GEM, .77; GDI and IDV, .77; GDI where sex reassignment procedures are paid for by national
and %NHS, .67; GEM and IDV, .84; GEM and %NHS, .57. In a multiple health insurance programs when provided through officially
regression analysis, when GDI and GEM were added to IDV, PDI, UAI,
designated clinics, nonhomosexual MtF transsexuals—who
MAS, and GNI/capita as predictors of %NHS, R2 = .82, R2 Adj = .72,
and IDV remained the only statistically significant predictor of %NHS are usually assumed to be wealthier than their homosexual
(cf. Table 4, first column). counterparts—plausibly may be underrepresented in reports
123
Arch Sex Behav (2010) 39:573–583 581
from such clinics, because they are arguably better able to ones (perhaps due to differences in child-rearing practices),
afford alternative, privately provided services. Conversely, this might hypothetically result in a higher prevalence of
in countries where sex reassignment services are not covered autogynephilia in individualistic countries than in collectiv-
by national health insurance, homosexual MtF transsexuals istic countries. Hypothetically, the underlying prevalence of
may plausibly be underrepresented in reports from private male androphilia might also be different—perhaps lower—in
clinics that provide sex reassignment services, because these individualistic countries than in collectivistic countries, al-
transsexuals are arguably less able to afford privately pro- though the strong biological underpinnings of male andro-
vided services. philia might argue against the idea that differences in cultural
Yet another limitation of the analysis involves possible values and practices would significantly affect its prevalence.
inaccuracies in the assessment of sexual orientation in the Given the observation in the present study that differences
studies analyzed. It is not unusual for nonhomosexual MtF in societal individualism were strongly predictive of differ-
transsexuals to misrepresent themselves as homosexual ences in the relative prevalence of homosexual and nonho-
(Freund, 1985); consequently, the percentage of nonhomo- mosexual MtF transsexualism between countries, one might
sexual transsexuals in a study can easily be underestimated by wonder whether a similar pattern would be observed among
investigators. For some studies (e.g., Rehman et al., 1999; population groups within countries. Although the data are
Smith et al., 2005), the availability of information concerning inconsistent, there is some evidence that, in the United States,
previous marriages or sexual partnerships with women al- persons of color in general, and Hispanic Americans and
lowed the reported figures for nonhomosexual orientation to Asian Americans in particular, tend to be less individualistic
be critically appraised and adjusted when necessary. For most (or more collectivistic) than European Americans (Gaines
studies, however, no such information was available. In the et al., 1997; Oyserman et al., 2002). There is also some evi-
study by De Gascun et al. (2006), marital history almost dence that nonhomosexual orientation may be less prevalent
certainly provided an underestimate of nonhomosexual ori- among MtF transgender persons of color than among MtF
entation, but no better measure was available. transgender persons of European American ethnicity. For
The factors that contribute to the observed association be- example, Kellogg, Clements-Nolle, Dilley, Katz, and
tween societal individualism and the relative prevalence of McFarland (2001) studied 238 self-identified MtF trans-
nonhomosexual MtF transsexualism remain to be determined. gendered persons who sought anonymous HIV testing in San
I have proposed that a greater tolerance within individualistic Francisco, most of whom were persons of color (29% His-
countries for socially disruptive gender transitions by nonho- panic American, 25% African American, and 14% Asian
mosexual gender dysphoric men, and the availability within American, versus 29% European American). Among the 195
many collectivistic countries of socially approved transgender participants who provided information about their sexual
roles for pervasively feminine homosexual gender dysphoric orientation, only 71 (36%) identified as ‘‘lesbian’’ or
men, may plausibly explain this association. However, the ‘‘bisexual’’; the remainder identified as ‘‘heterosexual’’ (i.e.,
qualitative, cross-cultural studies that could help decide the presumably androphilic), ‘‘homosexual male,’’ or ‘‘other.’’ If
validity of these explanations have yet to be conducted. the 36% figure provides an accurate estimate of the preva-
Moreover, the explanations I presented contained an unstated lence of nonhomosexual orientation among Kellogg et al.’s
assumption: that the prevalence of the erotic interests thought participants, then this represents a lower percentage of non-
to underlie homosexual and nonhomosexual MtF transsexu- homosexual orientation than was found in any of the three
alism—male androphilia and autogynephilia, respectively— studies from the United States that were included in the
probably do not vary greatly between countries, but that cross- present analysis.4 Unfortunately, most studies conducted in
cultural differences in the ways that these erotic interests are the United States that have asked about the sexual orientation
expressed (or not) are responsible for the observed differences of ethnic-minority MtF transgender persons have provided
between countries in the relative prevalence of homosexual
and nonhomosexual MtF transsexualism. This assumption, 4
The study by Kellogg et al. (2001) did not meet inclusion criteria for
while not unreasonable, might be incorrect. Hypothetically, the present analysis, because the participants were not described as
the underlying prevalence of autogynephilia might be differ- living full-time as women, having completed SRS, or having been
ent—perhaps higher—in individualistic countries than in diagnosed with gender identity disorder, transsexualism, or gender
dysphoria. Moreover, MtF transgender persons who seek anonymous
collectivistic countries. For example, if disturbances in young
HIV testing may be unrepresentative of MtF transgender persons
children’s relationships with their primary caregivers and generally with respect to sexual orientation, in that exclusively gyne-
consequent separation anxiety contribute to the development philic persons may be less likely to request such testing. Finally, ethnic
of autogynephilia, as some psychoanalytic theories of trans- minority groups appear to have been significantly overrepresented
among the Kellogg et al. participants, relative to United States
vestism and transsexualism implicitly suggest (see Person &
population norms. If the Kellogg et al. study had been included in the
Ovesey, 1978), and if such disturbances were to occur more present analysis, the correlation between IDV and %NHS would have
frequently in individualistic countries than in collectivistic been .84.
123
582 Arch Sex Behav (2010) 39:573–583
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Arch Sex Behav (2010) 39:213–215

LETTER TO THE EDITOR

(Self-)Abusive Prophecies, Rigorous Science, and Discursive

Published online: 26 September 2009

Edelman, L. (2004). No future: Queer theory and the death drive.

LETTER TO THE EDITOR

An Explanation for the Shape of the Human Penis

Published online: 23 October 2009

Reports from the DSM-V Work Group on Sexual and Gender

Published online: 16 September 2009

The DSM Diagnostic Criteria for Hypoactive Sexual Desire

Published online: 24 September 2009

6 months or more. 27.9% of those

FSDS cut-off score of 8.75, 23%

34% had low desire, overall 10%

Distress not assessed but 10.7% reported lack of desire for

55% had low desire. Using a

had low desire and distress

had low desire and distress

Consider the situation in which a woman desires sexual activity

treatment seeking was

Female Sexual Distress

the woman’s low desire is only relative to her partner’s some-

what higher desire. Another illustrative situation is the case of

both of these scenarios, appreciating the relational influences

sex for six months or

Desire assessed with

be with a dimensional criterion, as was proposed in the assess-

ment of distress. Such a ‘‘relational influences’’ specifier would

capture, on a Likert scale, the extent to which relationship-

related factors may be implicated in the etiology or maintenance

sional criterion would require empirical justification in field

trials. Thus, the woman for whom a lack of sexual desire is

16–44 Not necessary

completely attributed to partner-related factors would still meet

criteria for a desire disorder; however, the clinical recommen-

contextual descriptor from the 2003 Consensus committee

The Judgment of Deficiency is Determined

Criterion A of HSDD in the DSM-IV-TR (American Psychi-

nician in making the judgment, and whether judgment possesses

validity and inter-rater reliability, this statement does emphasize

Committee also recommended that ‘‘The lack of interest is

considered to be beyond a normative lessening with life cycle

and relationship duration’’ (Basson et al., 2003). It has been

established that sexual intercourse frequency declines with rela-

Not Better Accounted for by Another Axis I Disorder Terminology

Recommendations Table 2 Proposed criteria for Sexual Interest/Arousal Disorder (or

The DSM Diagnostic Criteria for Female Sexual Arousal Disorder

Published online: 24 September 2009

only impaired vaginal lubrication and not subjective response. Background

Study N of women Country Age Method of assessment Time period Prevalence

VPA response of women with subjective or combined symp- Criterion B

Proposed Revision to DSM-IV Category of FSAD Specifiers

The DSM Diagnostic Criteria for Female Orgasmic Disorder

Published online: 26 September 2009

Table 3 Prevalence of orgasm problems in selected epidemiological studies

The DSM Diagnostic Criteria for Sexual Aversion Disorder

Published online: 26 September 2009

Prevalence Causal Mechanisms

The DSM Diagnostic Criteria for Vaginismus

Published online: 23 October 2009

Self-Reported Behavior The empirical literature concerning the diagnosis of vaginis-