Rape as Mental Illness: Paraphilic Coercive Disorder

In November, forensic psychiatrists attending a conference of the American Association of Psychiatry and Law (AAPL) voted down three new sexual diagnoses proposed for inclusion in the DSM-V. One of the proposed diagnoses, Paraphilic Coercive Disorder, would essentially create a psychological disorder for rapists: rape as mental illness.

The vote does not exert a direct influence on the DSM-V, but the symbolism is powerful.

According to the DSM-5 Development site, the diagnostic criteria for Paraphilic Coercive Disorder are:

A.    Over a period of at least six months, recurrent, and intense sexual arousal from sexual coercion, as manifested by fantasies, urges, or behaviors.
B.     The person has clinically significant distress or impairment in important areas of functioning, 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.

If included in the DSM-V, Paraphilic Coercive Disorder would essentially turn “rape” into a medical condition, opening the door for defense attorneys to argue “diminished capacity,” and perhaps even “irresistible impulse” in some jurisdictions.

The placement of “or” under criteria B strikes me as significant, because (as I read it) it means someone could receive the diagnosis without actually having committed three or more rapes. “Clinically significant” distress about coercive fantasies would suffice. How far would the fantasies have to go? What if a man feels aroused by fantasies of tying up his girlfriend? What if he feels ashamed of that? How much shame would he need to feel to qualify as “clinically significant?”

In addition, it appears one would not have to be a serial rapist to have Paraphilic Coercive Disorder, which also means this particular sexual disorder makes no distinction between serial rapists and other kinds of rapists. Granted, I am not a psychiatrist. Perhaps there is some distinction here I fail to see.

Most of all, though, I wonder about the impact of this disorder (should it make its way into the DSM-V) on “Sexually Violent Predator” civil commitments. Civil commitments occur after sex offenders have served their sentences. Instead of locking up sex offenders based on jury convictions, though, the state locks them up for crimes not yet committed. The basic premise is that “sexually violent predators” are likely to strike again.

For an example of a civil commitment statute, check out King County, WA. Notice that civil commitment requires a mental abnormality or personality disorder in addition to a prior sex offense conviction.

“Paraphilic Coercive Disorder” seems broad enough to make SVP determinations easier-perhaps even easier enough to expand them. This leads me to wonder what kinds of processes-scientific, legal, ethical-exist to monitor the creation of psychological disorders. Does the state influence the creation of new disorders to justify (and simplify) “sexually violent predator” evaluations? If so, can they get away with it-and what does that mean for civil liberties?

What about forensic psychiatrists? Might they want to create disorders to simplify SVP evaluation? Probably not. After all, forensic psychiatrists voted this disorder down. More than once. Even still, it raises questions about the relationship between psychiatric professionals and the legal system. 

For more on this issue, read my previous post.

For a very interesting discussion, read here.

It turns out, I am not the only one worried about potential influence of government evaluators on the creation of new disorders.