Medicalising rape?:Paraphilic Coercive Disorder
Knight RA (2009). Is a Diagnostic Category for Paraphilic Coercive Disorder Defensible? Archives of sexual behavior PMID: 19888645
Does the proposed diagnostic category medicalise rape or at least medicalise rape fantasy?
The clamour for new disorders to be registered in the latest revision of the Diagnostic and Statistical Manual is nothing new: see this post looking at the proposal to enter “Extreme racism“. Some of these proposed classifications are more valid then others and have a greater weight of evidence to support their inclusion. I should point out that I am no Szass inspired anti-psychiatry ideologue but that I do believe there are certain diagnostic categories that are perhaps unnecessary and well covered by others.
For instance I am somewhat unconvinced that social anxiety disorder is a distinct category in of itself as oppossed to a component of another psychological issues. Be it generalised anxiety disorder, panic disorder or the like: in some cases I wonder if it would be more appropriate to classify it in terms of a social phobia. However I am always open to re-evaluating my position on this or any other diagnostic cateogry in the light of evidence. I would also stress that I don’t doubt that there is a highly distressing condition that has an huge impact on individuals daily lifes – just that I think it’s part of a wider disorder than a distinct seperate one.
In this case I doubt the validity of the inclusion of Paraphilic Coercive Disorder as a diagnostic catergory.
The proposed revision for the DSM-5 (Roman numerals are clearly out of fashion!)
Paraphilic Coercive Disorder
A. Over a period of at least six months, recurrent, intense sexually arousing fantasies or sexual urges focused on sexual coercion. 
B. The person is distressed or impaired by these attractions, or has sought sexual stimulation from forcing sex on three or more nonconsenting persons on separate occasions. 
C. The diagnosis of Paraphilic Coercive Disorder is not made if the patient meets criteria for a diagnosis of Sexual Sadism Disorder.
The notes accompanying this can be found here.
A major bone of contention with the proposed diagnostic criteria arises from opposition to the idea that it will result in the medicalisation of rape as the disorder is most widely reported by rapists who are receiving treatment:
Coercive sexual fantasy is commonly reported by rapists while participating in treatment (McKibben, Proulx, & Lusignan, 1994), and under optimal conditions in laboratory tests, about 60% of rapists demonstrate preferential arousal to saliently-coercive rape stimuli as compared to 10% of unconvicted individuals (Lalumière, Quinsey, Harris, Rice, & Trautrimas, 2003). Among convicted rapists it is those who have more persistently engaged in rape and assault who are more likely to show preferential arousal to saliently-coercive rape in laboratory tests (Willmot & Hart, 1996). Among individuals with no official record of sexual offending, preferential arousal to saliently-coercive rape as indicated by laboratory tests is found to be substantially correlated with self-report of engaging in sexually coercive behavior in the great majority of studies (Bernat, Calhoun, & Adams, 1999; Lalumière & Quinsey, 1996; Lohr, Adams, & Davis, 1997; Malamuth, 1986).
The concern stems from the idea that lawyers will use the diagnosis of Paraphilic Coercive Disorder as a means of “excusing criminals” on the basis of diminished responsibility. An idea that seems worryingly plausible. Presumably the driving force behind the proposal to add these criteria to the DSM is that potential rapists can be identified and treated before they commit any crime: although this appears to me to rely on a couple of assumptions –
One: That people who fantasize about rape go on to become rapists and
two: That these fantasies are unwanted and cause enough distress to seek treatment.
I doubt that there is much support for either of these assumptions and this adds to my growing feeling of unease that the diagnosis would become not much a a post-hoc excuse employed by lawyers and defence teams as a means of excusing defendants behaviours and reducing sentences for rape. In short it would add yet more unnecessary complexity to an already controversial system which many would argue is already clearly biased towards the defendants.
I could probably summarise my views on the validity of the diagnostic criteria with the following: “Many people fantasize about killing their boss but if they actually kill them this would be further evidence of their guilt rather than any diminished responsibility.”
In 2009 Richard Knight explored the evidence for Paraphilic Coercive Disorder and in his paper “Is a Diagnostic Category for Paraphilic Coercive Disorder Defensible?”. He summarised that the main evidence for Paraphilic Coercive Disorder being included as a diagnostic category stemmed from phallometric studies however he contends that they don’t necessarily show that arousal results from exposure of coercive stimuli but simply that coercive stimuli does not impair arousal when sexual stimuli is also presented. In addition, sexual fantasies about forcing sex and about struggling victims are highly correlated with sadistic fantasies and have not been shown to identify a syndrome that can be discriminated from sadism.
Knight concludes that there is little empirical justification to back up the inclusion of Paraphilic Coercive Disorder as a separate category and to do so would merely be to add an arbitrary diagnostic criteria to the DSM-5. He also shares my concerns that the potential for the diagnosis outweights any spurious potential benefits from inclusion:
Not only does there seem to be little empirical justification for the creation of this new syndrome, the inclusion of this disorder among the paraphilias would have serious potential for misuse. It would imply endorsement of Paraphilia, NOS, nonconsent, which is currently inappropriately employed in civil commitment proceedings to justify commitment.