“…when there are clear boundaries between classes, and when the different classes are mutually exclusive” 
(APA,  2000, p. xxxi). 

Although the text acknowledges problems with the categorical approach, these problems are particularly evident with the Paraphilias. 

The Paraphilia disorders do not have clear boundaries (Laws & O’Donohue, 1997). Non-clinical studies of individuals with unusual sexual interests demonstrate that these individuals are indistinguishable from those with “normophilic” (i.e., conventional) sexual interests 

(Brown et al., 1996; Fagan, Wise, Schmidt, Ponticas & Marshall, 1991). 

The clinical studies do not identify a discernible group who have anything more in common than their shared sexual interest. The existing empirical research does not distinguish individuals with Paraphilias from those with other mental disorders. That is, there is no demonstrable and distinct class of “paraphiliacs”, except as created by defining specific sexual interests, a priori, as evidence of psychopathology. 

The inability to define “healthy” sexuality or to distinguish the characteristics of individuals with a paraphilia from those without one, suggests that the distinction does not exist and the category is invalid. 

Individuals can and do experience psychiatric problems related to their sexual interests and behavior. Problems related to normophilic sexual interests or behaviors, associated with distress or dysfunctions, are dealt with differently and given non-sexual diagnoses. We can find no logical or scientific reason why some sexual behaviors and interests have been designated as Paraphilias and others have not. 

The DSM Definition of a Paraphilia 

"The essential features of a Paraphilia are recurrent, intense sexually arousing fantasies, sexual urges, or behaviors … that occur over a period of at least 6 months …” (APA, 2000, p. 566).

The definition of intense is the issue; otherwise this statement in isolation describes healthy, sexually active individuals. The DSM already defines terms such as compulsive, impulsive, and obsessive; so intense in this situation must have a different implication. 

Even trained clinicians have difficulty distinguishing strong “unhealthy” sexual interests from strong “healthy” sexual interests, as demonstrated by previous, failed attempts to define

Conversely, individuals lacking intense sexual arousal may be subject to diagnosis with a Sexual Arousal Disorder or Hypoactive Sexual Desire Disorder. The editors further qualify their paraphilia definition by stating, 

“…generally involving 
1) nonhuman objects, 
2) the suffering or humiliation of oneself or one’s sex partner, or 
3) children or other nonconsenting persons…” (p. 566). 

The implication is that the distinction between a mental disorder and a healthy sex interest is based in the nature of the specific sexual interest rather than in its intensity. The following statement found later in the text, reinforces that point: 

“Of course, for the specific diagnosis to be assigned, the particular pattern of paraphilic arousal must also be present" (p. 840). 

Although a less intense interest in the "unhealthy" behavior or an intense interest in a “healthy” behavior does not qualify for a paraphilia diagnosis, the distinction appears to be based upon the focus of the sexual interest rather than its intensity. 

An intense interest in conventional sexual behavior was once considered a criterion for a valid diagnosis. Nymphomania, satyriasias, and erotomania were not included in the current DSM for the same reasons that homosexuality was removed, i.e., the lack of data to support inclusion and the recognition that these diagnoses impose a cultural value judgment on the behavior, rather than comprising a diagnosable entity. 

The tradition of identifying specific sexual behaviors as pathological predates the DSM-I (1952), possibly originating with Krafft-Ebing (1965/1886). It is a remnant of the reclassification of sexual sin to sexual pathology in the 19th century (Bullough & Bullough, 1977). 

The specifying of behaviors creates problems for at least six reasons: 

1. A behavior in and of itself is not evidence of psychopathology. Even when a behavior is construed as a symptom of a mental disorder, we do not classify the mental disorder by the symptom or the behavior. 
   Paranoia may be a symptom of several psychiatric diagnoses (e.g., schizophrenia, paranoid personality disorder, delusional disorder, psychoactive substance use, bipolar disorder), 
   but paranoia by itself is not a diagnosis. 
   Compulsive hand washing may be a symptom of obsessivecompulsive disorder, but it is not a hand-washing disorder. 
    
2. The act of specifying particular, sexual behaviors as pathological leads to discrimination against all practitioners of those behaviors, even when their behavioral expressions are appropriate and benign. 
   Furthermore, at present, the urges may be construed as pathological even if one never acts upon them. 
    
3. Specifying particular behaviors allows for the inference that other (i.e., unclassified) behaviors are unlikely to be the source of difficulties. 
   As most practitioners in the field know, normative heterosexual behaviors can be problematic, as well (cf., Kafka & Hennen, 1999). 
    
4. Specifying the behavior focuses the evaluation and treatment on that behavior. Some individuals do experience problems related to their sexual interests and these may be an appropriate focus of therapy. 
   However, the clinician may be diverted from any underlying concerns and attend unduly to controlling the specified behavior (Moser & Kleinplatz, 2002). 
    
5. Social, political, religious and historical factors affect the inclination to see certain behaviors or sexual proclivities as pathological (Bullough, 1988; Davis, 1996, 1998). 
   As acknowledged in the DSM (APA, 2000), these cultural values are a confounding influence and are contrary to the supposedly objective perspective of the DSM. 
    
6. The therapist’s own socialization or theoretical perspective is likely to affect judgments of health or pathology. This adds an unwelcome and inevitably, subjective component to an allegedly objective process. 

Changes to the Diagnostic Criteria 

It has been asserted that, 

“…all proposed changes were limited to the text sections…[and] no substantive changes in criteria were considered” (APA, 2000, p. xxix). 

This is patently false; the criteria for Exhibitionism, Frotteurism, Pedophilia, Sexual Sadism, and Voyeurism (i.e., “criminal” paraphilias) were changed and these changes were substantive.

Of note, the Paraphilia section appears to be the only section of the DSM-IV-TR (APA, 2000) to which changes to the diagnostic criteria were made. The impetus for these changes is not stated.

There are essentially two changes for each of the above diagnoses. 

The inclusion of nonconsent is especially problematic in the case of Sexual Sadism. Although it is clearly possible for an individual with the diagnosis of Sexual Sadism to engage in nonconsensual acts, most “sadists” do not seek non-consenting partners 

(Moser, 1999; Weinberg, Williams, & Moser, 1984). 

Just as it is inappropriate to confuse rapists with those individuals interested in consensual sexual activities, the lumping of individuals interested in consensual sexual sadism with those who engage in non-consensual activities is similarly inappropriate (McConaghy, 1999). 

One can conclude the editors of the DSM appear to reject the possibility that anyone would engage willingly in these activities, despite a now sizeable professional and lay press which indicates just that. The application of the current DSM criteria may result in many rapists being diagnosed inappropriately with Sexual Sadism. 

The data suggest that the majority of rapists are not motivated by sadism (Groth & Hobson, 1983; Hucker, 1997); correspondingly, there is no data to suggest that rape is more common among practitioners of Sexual Sadism. It is noteworthy that “rape” was removed from the DSM with the publication of the second edition (1968). It is not clear why the concept is being reintroduced into the DSM at this time. 

The “B” Criterion: Distress and Dysfunction and the “Paraphilias” 

An essential criterion for making the diagnosis of paraphilia is that the behavior, urges, or fantasies cause distress or dysfunction. These two symptoms will be analyzed separately.

Distress 

It is acknowledged in the DSM that, 

"These individuals are rarely self-referred and usually come to the attention of mental health professionals only when their behavior has brought them into conflict with sexual partners or society” (APA, 2000, p.566). 

Possibly for emphasis, the DSM includes the statement: 

“Many individuals with these disorders assert that the behavior causes them no distress and that their only problem is social dysfunction as a result of the reaction of others to their behavior” (p. 567). 

One must conclude that distress is rarely a problem for those individuals diagnosed with a paraphilia. 

Consider the minority of individuals diagnosed with a paraphilia who are distressed because of their sexual interests. Although one’s sexual interests, “tend to be chronic and lifelong” (APA, 2000, p. 568), there is no indication that the distress is chronic. 

This distinction has been overlooked in the diagnostic criteria. If the distress can be mitigated, would these individuals cease to be diagnosable as having Paraphilias? Support groups can alleviate social stigma and isolation. Although they are helpful to mitigate this distress, they are rarely mentioned in the clinical literature in regard to the treatment of the Paraphilias (Moser, 1988; 1999). 

A strict reading of the definition of a mental disorder suggests that the distress must be “present distress” (APA, 2000, p. xxxi), which implies that if the distress is mitigated, the individual no longer meets the criteria for the diagnosis. 

Some individuals sincerely wish to change their sexual interests and have not found solace from or are unwilling to attend support groups. These individuals should be treated in a similar fashion to those who are uncomfortable with their sexual orientation. 

One may question why an individual with a paraphilia does not give up the sexual interest that results in adverse consequences. This has been interpreted as further evidence of the compulsive nature of these “disorders.” Even if individuals exhibit compulsive fantasies, behaviors and urges, compulsivity is not included in the diagnostic criteria of the paraphilias, and should have no bearing on the diagnosis of a paraphilia. 

Furthermore, how many “normal” heterosexuals would be able to eliminate their interests if the laws suddenly changed? We wonder why individuals who refuse to change unpopular political or religious beliefs are not similarly diagnosed. It is worth considering the possibility that unusual sexual interests might enhance one’s quality of life rather than diminishing it.

Proscribed fantasies, desires, and behaviors may not be pathological; healthy individuals resist giving up life-affirming and enhancing experiences, regardless of social mores.

Historically, social and psychiatric sanctions have done little to decrease the incidence of other forbidden sex acts 

(bearing children outside of marriage, extramarital sex, and masturbation), 

but have caused the participants significant distress and misery.

It is important to distinguish carefully between 

The perseverance of gay rights activists in the face of the “diagnosis and treatment” of homosexuality provides an excellent example of this courage. 

Discrimination can also lead to distress. It is difficult to argue that individuals suffer from mental disorders solely because they must deal with the consequences of discrimination. This would lead to diagnosing people for being homosexual, African-American, female, Communist, or Wiccan. When individuals in these “minority” groups present to therapists with problems related to the discrimination that they experience, “therapy” focuses on the development of coping strategies. Their minority status is not the diagnosis. 

Dysfunction 

The “B” criterion allows for the diagnosis if there is,

“…impairment in social, occupational, or other important areas of functioning" (APA, 2000, p. 566). 

The implication is that the dysfunction results from the paraphilia per se, rather than social reactions to the sexuality. Theoretically, the paraphilia diagnosis might be justified if the patient was fired for being habitually late as a result of engaging in the paraphilic behavior. However, if one is fired solely due to the discomfort of others, it does not signify dysfunction on the part of the employee. 

Suppose an individual is functioning in society without difficulty and also has an interest in a Paraphilia, thereby satisfying the “A” but not the “B” criterion. Theoretically, that person would not be diagnosed with a Paraphilia. 

Now assume that an employer, spouse, or parent discovers this interest. This revelation leads to termination of employment, discord in the couple or family, etc. 

Whether the nature of the problem is a psychiatric dysfunction or practical difficulty is particularly murky. Social isolation may lead to depression; participating in support groups and in a subculture surrounding the specific sexual interest may lead to resolution of the alienation and associated depression without psychotherapy or anti-depressants. 

It is indicated in the DSM (2000) that individuals with paraphilias may be sexually dysfunctional. Although it is true that an individual with a paraphilia may be sexually dysfunctional, the DSM emphasizes causality 

("…result in sexual dysfunction" [p. 568]); 

this statement lacks the requisite supporting empirical data. 

Our review of the literature did not uncover any references suggesting correlation between sexual dysfunction and a diagnosis of a paraphilia, much less causation. It is unclear if the incidence of sexual dysfunction is higher or lower among those with a paraphilia, but sexual dysfunctions are exceedingly common in the general population, 

(Laumann, Paik, and Rosen, 1999). 

Brown et al. (1996) suggested that there is no difference between the sexual functioning of those diagnosed with a paraphilia compared to a “normal” sample. They reported that cross-dressers were indistinguishable from non-crossdressers on the Derogatis Sexual Functioning Inventory (DSFI). 

In addition, Wise, Fagan, Schmidt, Ponticas & Costa (1991) found no significant difference in sexual functioning as measured by the DSFI between “transvestitic fetishists” and “other paraphilics.” 

Could individuals with Paraphilias have impaired sexual responses to "normative" sexual interests and manifest sexual dysfunctions when presented with non-paraphilic stimuli? Although this is a common belief, it too, is not supported by the data. Individuals diagnosed with Paraphilias apparently have a wide range of interests, including normative sexual interests

(Langevin, Lang, & Curnoe, 1998). 

Conversely, “unusual” sexual interests are commonly found in the general population 

(Renaud & Byers, 1999; Sue, 1979). 

The DSM contains the statement, 

"There is often impairment in the capacity for reciprocal, affectionate sexual activity” (APA, 2000, p.567). 

The theme of reciprocal, affectionate sexual activity is repeated through several editions. In the DSM-III (1980), this phrase was used in conjunction with Ego-dystonic Homosexuality. Although this diagnosis was technically abandoned with the publication of DSM-III-R (1987), essentially the same wording remains in the description of Sex Disorder, Not Otherwise Specified in DSM-III-R (1987), DSM-IV (1994), and DSM-IV-TR (2000). 

The judgment of what constitutes reciprocal, affectionate sexual activity is clearly value laden and suggests an underlying, implicit, theoretical orientation. There are no data to suggest that individuals diagnosed with a paraphilia have any more difficulty maintaining relationships than “normal” heterosexuals, who have staggering divorce rates. 

When Do “Paraphilic” Sexual Behaviors Become Pathological?

The DSM is intended to help the clinician distinguish between healthy functioning and mental disorders. The DSM cautions, 

"A paraphilia must be distinguished from the nonpathological use of sexual fantasies, behaviors, or objects as a stimulus for sexual excitement" 
(APA, 2000, p. 568, emphasis in the original).

The statement implies, but does not state explicitly that the stimuli can include the paraphilic “fantasies, behaviors, or objects.” Guidance on how the clinician is to make this distinction is not given in the text. 

In keeping with the DSM definition of a mental disorder, any sexual behavior can signify pathology if it interferes with the individual’s functioning. However, the behavioral manifestations of a mental disorder should not be confused with the mental disorder or underlying problem itself. 

An individual with alcoholism may abuse other drugs if access to alcohol is limited. An individual with auditory hallucinations emanating from the radio may hear voices from other objects if the radio is removed. Similarly, an individual who crossdresses to relieve anxiety after arguing with his wife may benefit from marital therapy rather than “treatment” targeting his transvestic fetishism. 

Stopping the “problematic” sexual behavior does not imply any problem has been treated or that subsequent sexual expression will be “healthy.” 

Statements of Fact? 

The Paraphilia section contains a number of purportedly factual statements that do not appear to be supported by the research literature. For example, 

“…for Sexual Masochism …the sex ratio is estimated to be 20 males for each female” (APA, 2000, p. 568). 

No studies were found to support the 20 : 1 statement. Several studies were found that reported a significant number of women in the S/M subculture, 

(Breslow, Evans & Langley, 1985; Gosselin, Wilson, & Barrett, 1991; Levitt, Moser & Jamison, 1994). 

By combining the data of Breslow et al. (1985) and Levitt et al. (1994), a ratio of four male masochists to each female masochist was found. Even if clinical samples are overwhelmingly male, no study supports the naming of a specific ratio. 

The DSM-IV-TR states, 

“Approximately one-half of the individuals with Paraphilias seen clinically are married” (APA, 2000, p. 568). 

One study (Wise et al., 1991) appears to support that statement. That study involved 50 men, comprised of 24 “transvestitic fetishists” and 26 “other paraphiliacs.” The "other" types of paraphilias were not specified. However, only by combining the divorced, separated, and married category could one conclude that one-half the individuals were married. It is not clear if the “finding” that half are married is higher or lower than expected.

Of interest, the Paraphilias were the only diagnostic section to include information about marital status. The rationale for inclusion of this poorly substantiated "fact" is not clear. 

The purpose of many of the statements made in the Paraphilia section is nebulous. Some statements, while correct, are equally true for both those with a Paraphilia diagnosis as those judged to be normophilic. For example, 

“Frequent, unprotected sex may result in infection with, or transmission of, a sexually transmitted disease” (APA, 2000, p. 567) 
or, 
“The behaviors may increase…with increased opportunity” (p. 568). 

The implication is that those diagnosed with Paraphilias are more likely to have sexually transmitted diseases or difficulty engaging or refraining from their sexual interests than those with more conventional interests. Neither point is supported by data nor is the reason for their inclusion in the DSM apparent.

Another misleading statement is, 

“Sadistic or masochistic behaviors may lead to injuries ranging in extent from minor to life threatening” (APA, 2000, p. 567). 

Although any sexual activity can lead to injury, there is no data to suggest that the practitioners of "sadistic or masochistic behaviors" frequent emergency departments more often than practitioners of other sexual behaviors. A review of the sports medicine and emergency medicine literature reveals numerous studies of specific injuries related to various sports and other activities. If unusual sexual acts resulted in a significant number of injuries, presumably they, too, would appear prominently in the medical literature. 

Another erroneous statement is evident in the confusion of hypoxyphilia with sexual masochism. The DSM contains the following statement: 

“One particularly dangerous form of Sexual Masochism, called ‘hypoxyphilia,’ involves sexual arousal from oxygen deprivation…” (APA, 2000, p. 572). 

In fact there is no empirical data correlating hypoxyphilia to masochism. In their study of 117 fatal cases of autoerotic asphyxia, Blanchard and Hucker conclude, 

"In contrast to transvestism, bondage during the fatal asphyxial episode was not differentially associated with any specific erotic object or interest that we examined, even bondage pornography" (1991, p. 375). 

Some statements confuse rather than clarify the diagnostic process. For example, 

“For some individuals, paraphilic fantasies or stimuli are obligatory …. In other cases, the paraphilic preferences occur only episodically …” (APA, 2000, p. 566). 

Analogously, heterosexual fantasies or stimuli are obligatory for some heterosexuals, but in other cases occur only episodically. Again, the purpose of the DSM statement is questionable. 

The Special Case of Pedophilia 

The politics and moral outage surrounding the diagnosis of pedophilia are so pervasive that specific comments about this sexual interest must be explicit. 

Pedophiles occupy a particularly odious position in our society and suggestions that these individuals do not suffer from a mental disorder may be interpreted as support for their activities. We wish to clarify that our suggestion to remove the paraphilias, which includes pedophilia, from the DSM does not mean that sexual acts with children are not crimes. 

We would argue that the removal of pedophilia from the DSM would focus attention on the criminal aspect of these acts, and not allow the perpetrators to claim mental illness as a defense or use it to mitigate responsibility for their crimes. Individuals convicted of these crimes should be punished as provided by the laws in the jurisdiction in which the crime occurred. Any interpretation of our work as supporting adult-child sexual interactions is misguided and wrong. 

Discussion 

The Paraphilia section of the DSM (APA, 2000) does not meet the goals set forth in its text 

(i.e., "to correct any factual errors … to ensure that all of the information is still up-todate … to reflect new information available …. All changes proposed … had to be supported by empirical data … [and] were limited to the text sections" [p.xxix]). 

The premise of the DSM is that diagnoses should be based upon objective science and not on political or social motivations. Therefore, objective research is needed to substantiate statements that some forms of sexual expression are healthy and other forms constitute mental disorders. 

Although it may be tempting to generalize from one's clinical experiences, it is contrary to the premise and stated goals of the APA in the DSM. Without data to suggest that a behavior pattern is dysfunctional, one should either suspend judgment or assume the behavior pattern signifies a healthy, normal variation. Although that statement also has political ramifications, it is correct from a scientific perspective. 

The DSM criteria for diagnosis of unusual sexual interests as pathological rests on a series of unproven and more importantly, untested assumptions. Given the explicit intent to produce an empirically valid document, the DSM must provide supporting documentation. Even if future research should verify their current assumptions, they have been inserted into the DSM inappropriately at this time. In the interim, these untested assumptions can be and are being misused. 

The text of the DSM states, 

“…all changes proposed for the text had to be supported by empirical data” (2000, p. xxix). 

Although this goal is laudable, it can be interpreted as setting up an impossible burden for the removal of a diagnosis or category. If health cannot be defined, then it is impossible to prove that individuals currently subject to a specific diagnosis are actually “healthy” and not pathological. It is logically impossible to prove a negative. Diagnoses should be removed if they can not be shown to meet the definition of a mental disorder unambiguously and be substantiated by appropriate research. Failing that, the diagnosis in question should be either considered experimental or removed from the DSM completely.

Conclusion 

The present critique did not explore every problem in the Paraphilia section. Many more were found than could be documented here. It is obvious that the present diagnostic category has not fulfilled the criteria for inclusion set out in its own text; 

There are two possible solutions: 

Alternatives to the current paraphilia category have been proposed (see Moser, 2001, for one example), but a discussion of these alternatives is beyond the scope of the present paper. 

If the editors of the DSM choose to revise this section, they will need to 

Although a radical solution, we now favor removal of the entire category from the DSM as the most appropriate remedy for the problems outlined. 

There are individuals now diagnosed with a paraphilia who seek psychotherapy. We believe that other psychological characteristics describe these individuals and their concerns more accurately than their sexual interests do. It is not their sexual interests, but the manner in which they are manifest that can be problematic at times and is a more appropriate focus for therapy. 

A guiding principle in medicine is the dictum “First, do no harm." The confusion of variant sexual interests with psychopathology has led to discrimination against all "paraphiliacs." Individuals have lost jobs, custody of their children, security clearances, become victims of assault, etc., at least partially due to the association of their sexual behavior with psychopathology. 

This is not a new problem for psychiatry. Within the last 100 years, the labeling of other sexual behaviors as pathological (e.g., masturbation, “nymphomania,” homosexuality) has caused untold misery. 

Judgments should be made on the basis of science, rather than the morality that is popular at the time of a given edition. It is time to reevaluate rigorously the Paraphilia section of the DSM.

References 

American Psychiatric Association. (1952). Diagnostic and statistical manual: Mental disorders. Washington, DC: Author.

American Psychiatric Association. (1968). Diagnostic and statistical manual of mental disorders (2nd ed.). Washington, DC: Author. 

American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. 

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., Revised). Washington, DC: Author. 

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. 

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revised). Washington, DC: Author. 

Bayer, R. (1981). Homosexuality and American psychiatry: The politics of diagnosis. New York: Basic Books. 

Blanchard, R., & Hucker, S.J. (1991). Age, transvestism, bondage, and concurrent paraphilic activities in 117 fatal cases of autoerotic asphyxia. British Journal of Psychiatry, 159:371-377.

Brown, G.R., Wise, T.N., Costa, P.T., Herbst, J.H., Fagan, P.J., & Schmidt, C.W. (1996). Personality characteristics and sexual functioning of 188 cross-dressing men. The Journal of Nervous and Mental Disease, 184, 265-273. 

Bullough, V (1988). Historical perspective. In D. Dailey (Ed.), The sexually unusual: Guide to understanding and helping (pp. 15-24). New York: Haworth Press. 

Bullough, V., & Bullough, B. (1977). Sin, sickness, and sanity: A history of sexual attitudes. New York: New American Library.

Davis, D.L. (1996). Cultural sensitivity and the sexual disorders of the DSM-IV: Review and assessment. In J.E. Mezzich, A. Kleinman, H. Fabrega, & D. L. Parron (Eds.) Culture and psychiatric diagnosis: A DSM-IV perspective (pp. 191-208). Washington, DC: American Psychiatric Press. 

Davis, D. L. (1998). The sexual and gender identity disorders. Transcultural Psychiatry. 35, 401-412. 

Groth, N., & Hobson, W. (1983). The dynamics of sexual assault. In L. Schlesinger & E. Revitch (Eds.), Sexual dynamics of anti-social behavior. Springfield, IL: Thomas. 

Hucker, S.J. (1997). Sexual sadism: Psychopathology and theory. In D.R.Laws & W. O’Donohue (Eds.), Sexual deviance: Theory, assessment, and treatment (pp. 194-209). New York: Guilford Press. 

Kafka, M.P., & Hennen, J. (1999). The paraphilia-related disorders: An empirical investigation of nonparaphilic hypersexuality disorders in outpatient males. Journal of Sex & Marital Therapy, 25, 305-320. 

Krafft-Ebing, R. von (1965). Psychopathia sexualis. (F. S. Klaf, Trans.). New York: Bell Publishing Company, Inc. (Translated from the 12th German edition; original work published 1886).

Langevin, R., Lang, R.A., & Curnoe, S. (1998). The prevalence of sex offenders with deviant fantasies. Journal of Interpersonal Violence, 13, 315-327. 

Laumann E.O., Paik A., & Rosen R.C. (1999). Sexual dysfunction in the United States: Prevalence and predictors. Journal of the American Medical Association, 281, 537-544. 

Laws, D.R., & O’Donohue, W. (1997). Introduction: Fundamental issues in sexual deviance. In D.R. Laws & W. O’Donohue (Eds.), Sexual deviance: Theory, assessment, and treatment (pp. 1-21). New York: Guilford Press. 

McConaghy, N. (1999). Unresolved issues in scientific sexology. Archives of Sexual Behavior, 28, 285-302. 

Moser, C. (1988). Sadomasochism. Journal of Psychology and Human Sexuality, 7, 43- 56. Also published in D. Dailey (Ed.), The sexually unusual: Guide to understanding and helping. (pp. 43-56). New York: Haworth Press, Inc. 

Moser, C. (1998). S/M (sadomasochistic) interactions in semi-public settings. Journal of Homosexuality, 36, 19-29. 

Moser, C. (1999). The psychology of sadomasochism (S/M). In S. Wright (Ed.), SM Classics (pp. 47-61). New York: Masquerade Books. 

Moser, C. (2001). Paraphilia: Another confused sexological concept. In P. J. Kleinplatz (Ed.), New directions in sex therapy: Innovations and alternatives (pp. 91-108). Philadelphia: Brunner-Routledge. 

Moser, C., & Levitt, E. (1987). An exploratory-descriptive study of a sadomasochistically oriented sample. Journal of Sex Research, 23, 322-337. 

Moser, C., & Kleinplatz, P.J. (2002). Transvestic fetishism: Psychopathology or iatrogenic artifact? New Jersey Psychologist, 52(2) 16-17. 

Renaud, C., & Byers, E. S. (1999). Exploring the frequency, diversity and content of university students' positive and negative sexual cognitions. Canadian Journal of Human Sexuality, 8 (1), 17-30. 

Rubin, G. (1992). Thinking sex: Notes for a radical theory of the politics of sexuality. In C. S. Vance (Ed.), Pleasure and danger: Exploring female sexuality (pp.267-319). London, U.K.: Pandora Press. 

Silverstein, C. (1984). The ethical and moral implications of Sexual Classification: A Commentary. Journal of Homosexuality, 9 (4), 29 -37. 

Sue, D. (1979). Erotic fantasies of college students during coitus. Journal of Sex Research, 15, 299-305. 

Suppe, F. (1984). Classifying sexual disorders: The Diagnostic and Statistical Manual of the American Psychiatric Association. Journal of Homosexuality, 9 (4), 9-28. 

Weinberg, M.S., Williams, C.J., & Moser, C. (1984). The social constituents of sadomasochism. Social Problems, 31, 379-389.

Wise, T.N., Fagan, P.J., Schmidt, C.W., Ponticas, Y., & Costa, P.T. (1991). Personality and sexual functioning of transvestitic fetishists and other paraphilics. The Journal of Nervous and Mental Disease, 179, 694-698. 

Author Notes 

Correspondence concerning this article can be addressed to either Charles Moser, Ph.D., M.D., 45 Castro Street, #125, San Francisco, California 94114 (E-mail: docx2@ix.netcom.com) or Peggy J. Kleinplatz, Ph.D., 161 Frank Street, Ottawa, Ontario K2P 0X4, Canada (E-mail: kleinpla@uottawa.ca).