# 195 - 6D32 Paedophilic disorder # 6D32 Paedophilic disorder 577 Paraphilic disorders focused and intense sexual arousal pattern. At the same time, some individuals with voyeuristic disorder may use substances with the intention of engaging in voyeuristic behaviour that does reflect an underlying paraphilic arousal pattern. A diagnosis of voyeuristic disorder may be assigned together with a disorder due to substance use if the diagnostic requirements for both are met. Boundary with other mental disorders The occurrence or a history of behaviours involving observing an unsuspecting individual who is naked, in the process of disrobing, or engaging in sexual activity is insufficient to establish a diagnosis of voyeuristic disorder. Rather, these behaviours must reflect a sustained, focused and intense pattern of sexual arousal. When this is not the case, other causes of the behaviour need to be considered. For example, voyeuristic behaviours that do not reflect an underlying, persistent pattern of sexual arousal may occur in the context of some mental disorders, such as bipolar type I disorder during manic or mixed episodes, or dementia. Boundary with sexual crimes that do not involve a paraphilic disorder Sexual crimes involving voyeuristic behaviour may consist of actions or behaviours that are not associated with a sustained underlying paraphilic arousal pattern. Rather, these behaviours may be transient and occur impulsively or opportunistically. The diagnosis of voyeuristic disorder requires these behaviours to be a manifestation of a sustained, focused and intense pattern of sexual arousal. Paedophilic disorder Essential (required) features • A sustained, focused and intense pattern of sexual arousal – as manifested in persistent sexual thoughts, fantasies, urges or behaviours – involving pre-pubertal children is required for diagnosis. • The individual must have acted on these thoughts, fantasies or urges, or be markedly distressed by them. • The diagnosis does not apply to sexual arousal and accompanying behaviour between preor post-pubertal children who are close in age. Additional clinical features • Paedophilic disorder should not be diagnosed among children, and should be diagnosed only with the utmost caution among adolescents. Sexual experimentation is typical during adolescence, and sexual acts may occur impulsively or opportunistically rather than representing a recurrent pattern of sexual arousal. 6D32 Paraphilic disorders | Paedophilic disorder Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders • The diagnosis of paedophilic disorder is generally not adequately supported when the evidence indicating a sustained, focused and intense pattern of sexual arousal consists solely of a single or very limited number of instances of paedophilic behaviour, as there may be other explanations for specific occurrences (e.g. intoxication, opportunity). In the absence of a report of the individual’s sexual thoughts, fantasies or urges, examples of other forms of evidence supporting the presence of a paedophilic arousal pattern include a preference for specific types of pornography; preference over other forms of sexual behaviour; planning and repeatedly seeking out opportunities to engage in paedophilic behaviour; or laboratory measures of relative viewing time (based on the finding that preferred sexual stimuli are gazed at longer than non-preferred sexual stimuli) and/or penile plethysmography. • Some individuals with paedophilic disorder are attracted only to males, others only to females, and others to both. • Some individuals act on their paedophilic urges only with family members, others only with people outside their immediate family, and others with both. Boundary with normality (threshold) • A broad range of sexual behaviour with peers may occur in children or adolescents. A diagnosis of paedophilic disorder should not be assigned on the basis of sexual behaviours among pre- or post-pubertal children or adolescents with peers who are close in age. Course features • Individuals with paedophilic disorder often report the onset of paedophilic sexual interest during adolescence. • Paedophilic disorder is relatively stable after young adulthood, but sexual thoughts, fantasies, urges and behaviours may change over time, such that an individual who was assigned a diagnosis of paedophilic disorder no longer meets the diagnostic requirements. Developmental presentations • Advancing age may be associated with decreasing paraphilic sexual arousal and decreasing behavioural manifestations of paedophilic disorder due to increased impulse control and decreased sexual drive. Paraphilic disorders | Paedophilic disorder 579 Paraphilic disorders Culture-related features • Cultures vary in their legal definition of what constitutes a child or adolescent. The Tanner stages – a scale of physical development, including primary and secondary sexual characteristics across the lifespan – may provide a more objective basis than age on which to base a definition. • Cultures vary regarding the forms of affection that are considered appropriate between children and adults. For example, it is normative in some cultures for parents to kiss their children on the mouth as a sign of affection. Culturally normative behaviour should not be misattributed as inappropriate sexual activity. Sex- and/or gender-related features • Paedophilic disorder is much more prevalent among men. Boundaries with other disorders and conditions (differential diagnosis) Boundary with compulsive sexual behaviour disorder Both paedophilic disorder and compulsive sexual behaviour disorder may involve repetitive sexual impulses, urges or behaviours that result in marked distress or impairment. Paedophilic disorder is characterized by sexual impulses, urges or behaviours that are manifestations of a sustained, focused and intense pattern of sexual arousal involving pre-pubertal children. In contrast, compulsive sexual behaviour disorder is characterized by a persistent pattern of failure to control sexual impulses, urges or behaviours, regardless of the focus of sexual arousal. If an individual with paedophilic disorder is able to exercise some degree of control over the behavioural expressions of the arousal pattern, an additional diagnosis of compulsive sexual behavioural disorder is generally not warranted. Boundary with obsessive-compulsive disorder Some individuals with obsessive-compulsive disorder experience intrusive thoughts and images about possible attraction or sexual abuse of children. These are typically highly distressing to the individual, and are not accompanied by sexual arousal; they therefore do not reflect an underlying paraphilic arousal pattern, even though the individual may be concerned that they do. These individuals may also experience other ego-dystonic thoughts or images with sexual content that are not experienced as sexually arousing. Boundary with disorders due to substance use Episodes of impulsive or disinhibited sexual behaviour, including paedophilic behaviour, may occur during substance intoxication. Such episodes may not be a manifestation of a sustained, Paraphilic disorders | Paedophilic disorder