Editor's Note: The current DSM-IV has the same code, and additional
information on these disorders.
DSM III and Psychosocial Disorder in Childhood
The Diagnostic and Statistical Manual of Mental Disorders, Third Edition
(DSM-III), divides psychosexual disorders into four groups. Gender
identity disorders are characterized by the individual's feelings
of discomfort with an inappropriateness about his or her anatomic sex and
by persistent behaviors generally associated with the other sex. Paraphilias
are characterized by arousal in response to sexual objects or situations
that are not part of normative arousal activity patterns and that, in varying
degrees, may interfere with the capacity for reciprocal affectionate sexual
activity. Psychosexual dysfunctions are characterized by
inhibitions in sexual desire or the psychophysiological changes that characterize
the sexual response cycle. Finally, there is a residual class of other
psychosexual disorders that has two categories: ego dystonic homosexuality
and psychosexual disorders not elsewhere classified.
The only category specifically related to children is 302.60, Gender
Identity Disorder of Childhood
The diagnostic criteria for this category for females is:
A. Strongly and persistently
stated desire to be a boy or insistence that she is a boy (not merely a
desire for any perceived cultural advantages from being a boy).
B. Persistent repudiation
of female anatomic structures, as manifested by at least one of the following
1. That she will grow up to become a man (not merely in role).
2. That she is biologically unable to become pregnant.
3. That she will not develop breasts.
4. That she has no vagina.
5. That she has or will grow a penis.
C. Onset of the disturbance
The diagnostic criteria for males:
A. Strongly and persistently stated
desire to be a girl or insistence that he is a girl.
B. Either one or two.
1. Persistent repudiation of male anatomic structures as manifested by
at least one of the following repeated assertions:
a. That he will grow up to become a woman (not merely in role).
b. That his penis or testes are disgusting or will disappear.
c. That it would be better not to have a penis or testes.
2. Preoccupation with female stereotypical activities, as manifested by
a preference for either cross-dressing or simulating female attire or by
a compelling desire to participate in the games and pastimes of girls.
C. Onset of the disturbance
The essential feature of disorders in this sub-class is that unusual
or bizarre imagery or acts are necessary for sexual excitement. Such imagery
or acts tend to be insistently and involuntarily repetitive and generally
involve either 1) preference for use of a non human object for sexual arousal,
2) repetitive sexual activity with humans involving real or simulated suffering
or humiliation or 3) repetitive sexual activity with non consenting partners.
Since paraphilic imagery is necessary for erotic arousal, it must be included
in masturbatory or coital fantasies if not actually acted out. In the absence
of paraphilic imagery, there is no relief from erotic tension; and sexual
excitement and/or orgasm is not attained. The imagery in a paraphilic fantasy
(rape, S&M, bestiality, etc.) or the object of sexual excitement in
a paraphilia is frequently the stimulus for sexual excitement in individuals
without psychosexual disorder. Paraphilic imagery or the use of objects
would be considered normative in childhood masturbation sexual patterns
because of children's limited sexual knowledge and options. In that regard,
fetish behavior is not included as a diagnosis in childhood. Before the
onset of post pubescent partner sex, the criteria of “repeatedly preferred”
(to partner sex) is not assessable; and when masturbation is the only sanctioned
or available sexual option, the use of inanimate objects to enhance the
experience is common. When other options (partners) are sanctioned and
available, the “exclusive or consistently preferred” use of inanimate objects
is considered a fetish.
Although the age of onset for fetishes is in childhood or adolescence,
paraphilic attachments of childhood and adolescence may recede in their
importance or degree of dependency when other sexual options become available.
For example, the panty fetish (one of the most common) may begin in childhood
as a young boy stimulates himself with thoughts of, procurement of and
masturbation with or into female panties. However, the adult obsession
with collecting panties for sexual use, accompanied by diminished erotic
response to partner sex, is not necessarily the eventual result of this
early childhood fixation. The adult transition to gratifying partner sex
may be smooth and uncomplicated, with childhood sexual patterns giving
way to appropriate adult patterns as increasingly varied sexual options
and opportunities become available. The adult male's interest in panties
as a sexual stimulant may remain, but may become less important in the
overall adult sex pattern. Fantasies about panties as a part of sexual
arousal and/or masturbation, the purchase of panties as a personal gift
to the partner, requesting the partner to wear panties as a part of sexual
foreplay, etc., may not be considered a fetish because it is not the consistently
preferred, necessary or exclusive sexual pattern.
Sometimes a young boy's erotization of panties leads him to public behavior
that is socially unacceptable. Stealing panties from family members or
from clotheslines and peeping, especially in the windows of neighbors,
may bring a child to the attention of the police or mental health professionals;
and treatment is required. The behavior is asocial and may be obsessive,
but the diagnosis of fetishism is still premature: This and other asocial
behavior such as public exposing of genitalia, may or may not be accompanied
by a mental disorder; and a differential diagnosis is imperative. Given
the contradictory and confusing way that Western culture handles sexual
development, it is erroneous to assume that asocial sexual acts of children
are vis-a-vis characterological pathology.