The Development,Content Validation,and Pilot Testing of the Paraphilic Interests and Disorders Scale

Abstract

The prevalence rates of paraphilic interests and disorders in the general population have been understudied, in large part due to the lack of a standardized assessment measure. As a result, the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 provides little information regarding the prevalence of paraphilic disorders. The present study involved the development of a self-report measure, Paraphilic Interests and Disorders Scale (PIDS), that can be used to assess for the eight paraphilic interests/disorders in the DSM-5 for use with general population samples. Study 1 established the content validity of the PIDS using feedback from 22 experts in the field, and recommendations from these experts were utilized to modify the measure. In Study 2, the PIDS was piloted on 100 individuals in the general population, which supported the feasibility of implementation and its limited-efficacy. While the PIDS requires further psychometric support, the current research suggests the PIDS is a promising tool to gather self-report, population-based data on DSM-5 paraphilic interests and disorders.

Keywords

paraphilic interests paraphilic disorders diagnostic and statistical manual of mental disorders-5 sexual interests

Diagnostic manuals (i.e., the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5; American Psychiatric Association [APA], 2013] and the International Classification of Diseases—11^th Edition [ICD-11; World Health Organization (WHO), 2018] contain a category of disorders related to paraphilic interests (i.e., non-normative sexual interests). Concerns have been raised regarding the DSM-5 criteria for paraphilic disorders, including whether they are properly selected and defined, whether they can be widely applicable across cultures and time periods, and the lack of information regarding etiology and motivation for engaging in paraphilic behaviors (Balon, 2013; Bhugra et al., 2010; Fedoroff et al., 2013; Moser, 2019). Moreover, of the few studies that have examined the prevalence of paraphilic interests in non-clinical samples, empirical evidence suggests paraphilic interests may be relatively common among the general population (e.g., Baur et al., 2016; Dawson et al., 2016; Joyal & Carpentier, 2017).

Perhaps most importantly, little is known about the reliability and validity of paraphilic disorders compared to other diagnostic categories in the DSM-5 (Fedoroff et al., 2013); and it has been suggested this is likely a product of APA not funding field trials for the paraphilic disorders section (Joyal, 2021; Moser, 2019; Seto et al., 2016). These findings led Beech et al. (2016) to conclude that the diagnostic criteria for paraphilic disorders lack empirical support. As a first step to rectify some of the limitations related to the measurement of paraphilic interests and disorders, the present study sought to develop and pilot a self-report measure based upon the DSM-5 diagnostic criteria for paraphilic disorders, the Paraphilic Interests and Disorders Scale (PIDS), which could be used to assess for the prevalence rates of DSM-5 paraphilic interests and disorders within the general population. In Study 1, we sought to establish content validity for the PIDS using experts in the field and subsequently; in Study 2, we piloted the measure to assess feasibility of implementation and its limited-efficacy.

DSM-5 Paraphilic Disorders

The diagnostic criteria for paraphilic disorders in the DSM have evolved across editions (see Beech et al., 2016 for a detailed history). In the DSM-5, there is a distinction between a paraphilic interest (paraphilia) and a paraphilic disorder (Zgourides, 2020). A paraphilia is described as an “intense and persistent” non-normative sexual interest (APA, 2013), while a paraphilic disorder is defined as “a paraphilia that is currently causing distress or impairment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm to others” (APA, 2013, p. 685). Thus, an individual who has a paraphilic interest may not necessarily meet criteria for a diagnosable paraphilic disorder.

In the paraphilic disorders chapter, the DSM-5 includes eight paraphilic interests that can manifest as clinical disorders, including: voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, and transvestic disorder. Moreover, the DSM-5 contains two residual categories for individuals with paraphilic interests that do not meet criteria for one of the eight paraphilic disorders: other specified paraphilic disorder (OSPD) and unspecified paraphilic disorder (UPD). See Table 1 for the DSM-5 definitions of these interests. Generally speaking, each set of diagnostic criteria for the aforementioned paraphilic disorders requires “recurrent” and “intense” sexual arousal lasting “at least 6 months” (Criterion A), and the individual has “acted on these sexual urges with a nonconsenting person” or the sexual urges or fantasies cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (Criterion B).

Table 1.

DSM-5 Descriptions of Paraphilic Interests/Disorders and Prevalence.

	DSM-5 Definition	Male Prevalence	Female Prevalence
Voyeuristic disorder	“Intense sexual arousal from observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity” (p. 686)	12% highest possible lifetime prevalence based on non-clinical samples	4% highest possible lifetime prevalence based on non-clinical samples
Exhibitionistic disorder	“Intense sexual arousal from the exposure of one’s genitals to an unsuspecting person” (p. 689)	2–4% highest possible prevalence in non-clinical samples	“Uncertain,” but believed to be lower than males
Frotteuristic disorder	“Intense sexual arousal from touching or rubbing against a nonconsenting person” (p. 691)	Up to 30% in general population 10–14% clinical samples	Not reported
Sexual masochism disorder	“Intense sexual arousal from the act of being humiliated, beaten, bound, or otherwise made to suffer” (p. 694)	2.2% Australian non-clinical samples	1.3% Australian non-clinical sample
Sexual sadism disorder	“Intense sexual arousal from the physical or psychological suffering of another person” (p. 695)	2–30% clinical samples <10% civilly committed sex offenders	Not reported
Pedophilic disorder	“Sexual activity with a prepubescent child or children (generally age 13 years or younger)” (p. 697)	3–5% non-clinical samples	“Uncertain,” but believed to be lower than males
Fetishistic disorder	“Intense sexual arousal from either the use of nonliving objects or a highly specific focus on nongenital body part(s)” (p. 700)	Not reported	Not reported
Transvestic disorder	“Intense sexual arousal from cross-dressing” (p. 702)	“Rare”	“Extremely rare”
Other specified paraphilic disorder	“Is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific paraphilic disorder. This is done by recording ‘other specified paraphilic disorder’ followed by the specific reason (e.g., ‘zoophilia’).” (p.705)	Not reported	Not reported
Unspecified paraphilic disorder	“Is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific paraphilic disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis.” (p.705)	Not reported	Not reported

Prevalence

Notably, the DSM-5 presents little information about the prevalence rates for paraphilic disorders. Indeed, the manual states that “the population prevalence of [voyeuristic/exhibitionistic/frotteuristic/sexual masochism/sexual sadism/pedophilic/transvestic] disorder is unknown” or the rates are not reported at all (i.e., fetishistic disorder, OSPD, UPD). In some cases, the DSM-5 includes estimates of the “highest possible” prevalence rates that are drawn from both clinical and non-clinical samples (which are often not clearly referenced). Moreover, these rates are frequently based on research examining sexual acts related to the disorder (APA, 2013); thus, they do not account for those who have not acted on the behavior but may experience distress or impairment (see Beech et al., 2016). Reported prevalence rates for the eight paraphilic disorders as outlined by the DSM-5 are presented in Table 1.

Historically, prevalence rates in non-clinical samples have been difficult to obtain due to the changing diagnostic definitions (Craig & Bartels, 2021) and methodological obstacles (e.g., inadequate sample size, usage of convenience samples, no standardized measure for assessing these interests). Despite these barriers, researchers have gathered population-based prevalence estimates which constitute the most applicable approximations of the prevalence of paraphilic interests and disorders. Prior to the publication of the DSM-5, studies have examined paraphilic interests and/or behaviors in community samples, including voyeurism (Ahlers et al., 2011; Långström & Seto, 2006) and exhibitionism (Långström & Seto, 2006). Since the release of the DSM-5 in 2013, there have been several additional studies that have addressed the question of population prevalence. These studies represent a range of sample sizes (e.g., 614–10,044 participants), locations (e.g., Canada, Germany, Czech Republic), methodologies (e.g., telephone interviews, self-report surveys), and measures (e.g., the Paraphilia Scale, Seto et al., 2012; Questionnaire on Sexual Experiences and Behavior, Joyal & Carpentier, 2017). Results from these DSM-5 studies can be found in Table 2.

Table 2.

DSM-5 Paraphilic Interests/Disorders Prevalence Studies.

	Dawson et al. (2016)	Dombert et al. (2016)	Joyal & Carpentier (2017)	Seto et al. (2020)	Bártova et al. (2021)	Chan (2021)
Sample Size	N = 1,015	N = 8,718	N = 1,040	N =1,074	N = 10,044	N = 1,171
Country	Canada	Germany	Canada	Online sample	Czech Republic	China
Sexual Interest/Behavior Measure(s)	The Paraphilia Scale	Explicit Sexual Interest Questionnaire	Questions derived from the Questionnaire on Sexual Experiences and Behavior	The Paraphilia Scale	Questionnaire developed by the researchers based on ICD-10	The Paraphilia Scale
Methodology	Online self-report questionnaire	Online self-report questionnaire	Telephone interviews and online self-report questionnaire	Online self-report questionnaire	Online self-report questionnaire	In-person self-report questionnaire
Results Type	Percentage	Percentage	Percentage	Mean scores: Range from −3 (Very repulsive) to +3 (very arousing).	Percentage	Mean scores: Range from −3 (very repulsive) to +3 (very arousing)*
Voyeuristic	Interests 52% men 26% women	—	Interests 46.3% Behavior 34.5%	Interests 0.89 heterosexual men (HM) 0.45 non-heterosexual men (NHM) −0.84 heterosexual women (HW) −0.40 non-heterosexual women (NHW)	Interests 42.5% men 25.9% women Paraphilia 16.6% men 6.4% women	Interests −1.73
Exhibitionistic	Interests 6% men 6% women	—	Interests 30.6% Behavior 30.1%	Interests −1.75 HM −1.55 NHM −2.15 HW −1.89 NHW	Interests 14.3% men 7.4% women Paraphilia 3.0% men 1.5% women	Interests −2.13
Frotteuristic	Interests 19% men 15% women	—	Interests 26.7% Behavior 26.1%	Interests −1.17 HM −1.26 NHM −1.84 HW −1.59 NHW	Interests 31.1% men 15.3% women Paraphilia 12.7% men 3.9% women	Interests −1.73
Sexual Masochistic	Interests 15% men 17% women	—	Interests 23.8% Behavior 19.2%	Interests −0.26 HM 0.03 NHM 0.21 HW 0.54 NHW	Interests 10.0% men 8.0% women Paraphilia 3.5% men 2.3% women	Interests −11.39
Sexual Sadistic	Interests 19% men 10% women	—	Interests 7.1% Behavior 5.5%	Interests −0.52 HM −0.50 NHM −0.95 HW −0.37 NHW	Interests 6.8% men 6.1% women Paraphilia 2.1% men 1.7% women	Interests −10.31
Pedophilic	Interests 0.6% men 0.0% women	Interests 4.1% men Preferential Interest 0.1% men Behavior 3.2% men	Interests 0.6% Behavior 0.4%	Pedohebephilia Interests* −2.44 HM −1.80 NHM −2.88 HW −2.71 NHW	Interests 1.7% men 0.4% women Paraphilia 0.6% men 0.0% women	Interests −4.54
Fetishistic	Interests 28% men 11% women	—	Interests 44.5% Behavior 26.3%	Interests −0.06 HM −0.01 NHM −0.60 HW −0.24 NHW	Interests 25.9% men 10.6% women Paraphilia 10.1% men 2.4% women	Interests −3.29
Transvestic	Interests 12% men 12% women	—	Interests 6.3% Behavior 4.9%	—	Interests 5.4% men 2.0% women Paraphilia 1.1% men 0.3% women	Interests −3.30

*The range of means in Chan 2021 appears based on the total number of items in the Paraphilia scale that load on to each paraphilic interest; thus, the range may exceed each individual item score (range of −3 to 3).

Measurement Issues

Importantly, while these previous studies provide vital information to begin understanding paraphilic interests in non-clinical samples, the major concern is the validity of the measures used to establish these findings. To date, there is no comprehensive, universally utilized assessment of paraphilic interests and disorders as defined by the DSM-5 in clinical practice or research. While clinical interviews or phallometric testing (e.g., penile plethysmography) may be used in individual cases when assessing for paraphilic interests (Holoyda, 2020; Seto et al., 2016), it is neither feasible nor cost effective to gather prevalence data on large samples using these methods (Laws, 2009). Numerous studies have utilized measures that have no established validity or reliability in their assessment of prevalence rates (e.g., Bártová et al., 2021; Dombert et al., 2016; Joyal & Carpentier, 2017). Other studies include data from measures with some psychometric support, such as the Multiphasic Sex Inventory (MSI; Nichols & Molinder, 1984); Paraphilic Sexual Fantasy Questionnaire (PSFQ; O’Donohue et al., 1997); The Paraphilia Scale (Seto et al., 2012); Revised Screen Scale for Pedophilic Interest (SSPI-2; Seto et al., 2017); Severe Sexual Sadism Scale (SSSS; Nitschke et al., 2009); and Wilson Sex Fantasy Questionnaire (WSFQ; Wilson, 1978).

Recently, the Questionnaire for Evaluation of Paraphilic Disorders (Delcea & Siserman, 2020) has been proposed as a clinically reliable tool that can differentiate between clinical and non-clinical groups; however, its utility is limited by the length (i.e., 150 items) and it is only currently available in the Romanian language. Additionally, the Paraphilia Scale, a self-report measure capturing multiple paraphilic interests and behaviors described in the DSM-5, has been used in several studies (e.g., Bouchard et al., 2017; Chivers et al., 2014; Dawson et al., 2016; Seto et al., 2012, 2020); however, it requires further validation (Seto et al., 2020). Moreover, the Paraphilia Scale was originally developed to examine sadism and masochism. As such, there are multiple items for both of these paraphilic interests, whereas others (e.g., zoophilia) are represented by only one item, which has potential psychometric limitations such as the inability to calculate internal consistency, the influence of random measurement error, and issues of bias in the meaning and understanding of the construct (Chivers et al., 2014; Hoeppner et al., 2011; Seto et al., 2012, 2020).

Notably, the majority of these assessments and prior research studies do not reflect the current DSM-5 diagnostic language (e.g., Ahlers et al., 2011; Dawson et al., 2016; Joyal & Carpentier, 2017; Långström & Seto, 2006). Some of the questionnaires are too narrow in scope in that they do not assess for all eight paraphilic interests and disorders included in the DSM-5 (e.g., Dombert et al., 2016; Långström & Seto, 2006; Nitschke et al., 2009). Other times, the results for all paraphilic interests are not individually reported in results (e.g., Vander Molen et al., 2021 grouped categories of paraphilic interests together). Moreover, several of these questionnaires only inquire about the presence of sexual interests/fantasies, but not whether the respondent acted on the interest (e.g., O’Donohue et al., 1997; Wilson, 1978). Other studies fail to assess whether the paraphilic interest and/or behavior caused distress, impairment, or entailed an actual risk of harm to others (e.g., Dawson et al., 2016; Seto et al., 2012), which is relevant to the paraphilic disorder diagnostic criteria. Last, measures have been limited in their assessment of only current or recent reports of paraphilic interests or acts, and do not assess across the lifespan (e.g., Chan, 2021; Dawson et al., 2016; Seto et al., 2012). The presence of paraphilias can aid in predicting the onset of sexual offending (Baur et al., 2016) and sexual reoffending (Mann et al., 2010), so it is necessary to have measurement tools that are psychometrically sound.

The Present Research

Since the release of the DSM-5 in 2013, few studies have explored the frequency at which paraphilic interests and disorders occur in the community. Existing findings have been significantly limited, primarily due to issues with measurement (e.g., the lack of a comprehensive, valid self-report questionnaire that reflects the DSM-5 criteria). Based upon the limitations of previous measures of paraphilic interests and disorders, the overarching goal of the present study was to develop, establish content validity, and pilot an assessment tool that could be used to identify the prevalence rates of the eight specified paraphilic interests and disorders described in the DSM-5 in general population samples. Specifically, we developed the Paraphilic Interests and Disorders Scale (PIDS), a self-report measure based upon the diagnostic language and criteria used in the DSM-5. In Study 1, we sought to establish content validity for the PIDS by surveying experts in the field. In Study 2, we collected pilot data for the PIDS from 100 individuals in the general population to ensure the feasibility of implementation and to assess limited-efficacy. Ultimately, the finalized version of the PIDS can be used by researchers to gather self-reported, population-based data on paraphilic interests and disorders.

Study 1: Content Validation

Method

Participants and Procedure

The content validation of the Paraphilic Interests and Disorders Scale (PIDS; described below) was examined by having professionals (“experts”) who conduct research and/or clinical work with paraphilic interests/disorders provide structured feedback about the items on the proposed measure. This content validation process is based on Lynn (1986), who proposed that the degree to which experts agree on the relevance of content should inform the items that are included in an assessment instrument. The methodology involves content experts scoring proposed items on a measure as relevant or not, then utilizing a cutoff score to determine which item ratings are high enough to be included in the final measure (i.e., deemed by experts to be relevant to the construct being assessed). While originally developed for the health care field, this method has been used across a range of disciplines (Polit & Beck, 2006).

For the present study, there were two expert samples included: (1) individuals who have published theoretical or empirical peer-reviewed book chapters or manuscripts on paraphilic interests/disorders; and (2) individuals working in the field of sexuality and sexual offending who had clinical experience working with clients with paraphilic interests/disorders and who were invited via email invitations through professional listservs. The study was reviewed and approved by the Institutional Review Board at Fairleigh Dickinson University. If the expert agreed to participate, they completed the 15- to 20-minute survey. They were asked to respond to all of the questions of the Expert Content Validation Survey (described below) and provided open-ended feedback throughout. Experts also completed questions about demographics (e.g., age, gender, race/ethnicity) and education/career-related information (e.g., degree; field of study; clinical, publication, and research experience).

Selection of Experts

For the first sample, a list of experts was compiled through a review of researchers who had peer-reviewed journal articles, books, or book chapters on paraphilic interests/disorders. Relevant literature was identified through online searches in four databases: PsychInfo, PubMed, Criminal Justice Abstracts, and Medline Complete. These databases were selected to cover a range of relevant fields (e.g., psychology, criminal justice, medical), and each database includes between 610 (Criminal Justice Abstracts) and 5,200 (PubMed) scholarly journals. Given that the PIDS was based on the diagnostic criteria for paraphilic interests and disorders in the DSM-5, we searched for publications using the terms “paraphili*” and “DSM*.” The search was date-restricted from the year 1994 to the present search date (July 2020) in order to not include literature published prior to the DSM-IV. After removing duplicates across the databases, there were a total of 358 publications gathered from the initial search criteria. Then, the titles and abstracts of these publications were reviewed by the primary investigators based upon the following inclusion criteria: (a) the main focus must be related to one or more specific paraphilic interests/disorders outlined in the DSM (i.e., if a publication did not highlight at least one DSM paraphilic interest/disorder in the title or abstract, it was not included), and (b) the content must be written in the English language. The following types of literature were excluded: (a) single case studies, (b) studies focusing solely on psychopharmacology or medical findings, (c) book reviews, or (d) articles in which the paraphilic interests/disorder discussed was not an established category in the DSM-IV or DSM-5 (e.g., paraphilia not otherwise specified, nonconsent or hebephilia) as the PIDS only focuses on the eight specified categories from a psychological perspective. Ultimately, 145 publications met the inclusion criteria, and from these, a list of all of the authors was created. To be considered an expert, an author had to have: (a) published a manuscript, book, or book chapter as the first-author, or (b) published two or more pieces of literature (regardless of author order). There were a total of 101 experts who met these criteria¹. Extensive searches were conducted via Internet search engines to locate the email addresses for the authors. Initially, there were 86 Email addresses located for the 101 eligible experts; however, upon sending the first email invitation to participate in the study, there were 15 inactive email addresses which resulted in a potential sample of 71 experts (see Figure 1). Three rounds of emails were sent to the expert pool requesting participation in the content validation study. A total of 11 individuals completed the survey (15.5% response rate—which is consistent with other studies using expert reviewers which range from 2 to over 20; e.g., Olson, 2010). Subsequently, one respondent’s set of answers was removed as the expert emailed the primary investigator indicating that they misunderstood the purpose of the survey. The final sample for the literature review included 10 experts (14.1% response rate).

Figure 1.

Content validation expert selection process.

For the second sample, the invitation to participate in the content validation study was sent through two Northeast and one national (U.S.) listserv that targets individuals with professional experience in sexuality or sexual offending (e.g., researchers, clinicians, social workers, psychiatrists). The email invitation explicitly requested participation from only those professionals who considered themselves to be experts in the area of paraphilic interests and/or disorders. To ensure that the individuals who completed the survey were experts, they had to endorse having at least 15 clinical clients who identified as having paraphilic interests or diagnosed with a paraphilic disorder, and/or have at least 10 years of research experience with paraphilias/paraphilic disorders. Only one respondent was removed for not meeting these qualifications. The final number of experts recruited from listservs was 12.

Expert Demographics and Experiences

With the combined samples, there were a total of 22 experts. This number surpasses the recommended sample size for a content validation study of at least seven participating experts (DeVon et al., 2007; Polit & Hungler, 1999), as well as the number of experts cited in prior similar studies (i.e., range from 2 to over 20; Olson, 2010; Polit & Beck, 2006). Demographic, educational, and work experience for experts is presented in Table 3. All but two experts had clinical experience with paraphilic populations, with the average years in practice being 25 (range = 8–50). The majority of these experts (n = 15, 75.0%) had more than 50 clients with paraphilic interests, while the other 4 (20.0%) reported 16–50 clients and 1 (5.0%) reported 1–5 clients. For the 16 experts who reported research experience with paraphilic interests/disorders, the average years spent researching was 18.8 (range = 3–50). There were 17 experts who had published peer-reviewed manuscripts/book chapters on paraphilic interests/disorders, with an average publication number of 24.5 (range = 1–250).

Table 3.

Experts’ Demographic, Educational, and Work Experience.

	n (%)
Gender
Male	14 (63.6)
Female	7 (31.8)
Prefer not to answer	1 (4.5)
Race/ethnicity
Caucasian/Non-Hispanic	19 (86.4)
Hispanic or Latino	2 (9.1)
Jewish	1 (4.5)
Age
31–40	3 (13.6)
41–50	3 (13.6)
51–60	6 (27.3)
Over 60	10 (45.5)
Educational background
Ph.D. or Psy.D	11 (50.0)
M.D.	4 (18.2)
M.A.	7 (31.8)
Educational field
Psychology	12 (54.5)
Psychiatry	5 (22.7)
Social work	4 (18.2)
Philosophy	1 (4.5)
Work setting
Private practice	6 (27.3)
Academia	5 (22.7)
Government organization	4 (18.2)
Hospital	2 (9.1)
Other (i.e., community treatment center, retired, forensic setting)	5 (22.7)
Type of experience(s) that best describe their expertise with paraphilias/paraphilic disorder
Clinical practice	19 (86.4)
Publishing theoretical articles/chapters on the topic	13 (59.1)
Empirical research	8 (36.4)
Other (i.e., forensic evaluations, teaching, training, program development)	7 (31.8)

Materials

Paraphilic Interests and Disorders Questionnaire

The Paraphilic Interests and Disorders Scale (PIDS; See the final version in Supplement Appendix) was created by the authors using the wording of the DSM-5, with minor modifications aimed to enhance understanding from a range of reading and intellectual abilities. For example, the term “turned on” was used in parentheses in addition to the original DSM-5 wording of “sexual arous[al].” We also reviewed prior measures of paraphilic interests (e.g., Bártová et al., 2021; Seto et al., 2012) to further inform the wording and response options. The PIDS was created in consultation with a psychiatrist who served as a consultant on the DSM-5 and has expertise in clinical diagnosis and assessment. Previous researchers have collected data in-person (e.g., Ahlers et al., 2011; Chan, 2021) and telephone interviews (Joyal & Carpentier, 2017), and when online self-report surveys were compared to telephone surveys, higher reporting rates of paraphilic interests and behaviors were reported (Joyal & Carpentier, 2017); therefore, we have opted to use a self-report questionnaire.

The PIDS includes questions regarding whether the individual has experienced the eight identified paraphilic interests in the DSM-5 (i.e., voyeuristic, exhibitionistic, frotteuristic, sexual masochism, sexual sadism, pedophilic, fetishistic, transvestic).² For each interest endorsed, the respondent then completes follow-up questions related to the disorder criteria of the DSM-5; this included the 6-month duration, recurrence, and intensity of the sexual interest (Criterion A), and negative consequences as a result of the interest (i.e., distress, impairment, or acting on the interest has caused harm to others; Criterion B).

Expert Content Validation Survey

A self-report survey was created to gather feedback for the proposed PIDS from the experts in the field of paraphilic interests/disorders. For each of the eight paraphilic interests, experts were asked to indicate whether the item wording as written in the PIDS was relevant to the assessment of the paraphilic interest on a four-point Likert scale (1 = not relevant, 2 = somewhat relevant, 3 = relevant, 4 = very relevant). See Table 4 for the originally proposed PIDS paraphilic interest questions. If the expert responded with a 1 or 2 to these items, they were asked to provide suggestions for modifications to the wording or content to make the item “very relevant.”

Table 4.

PIDS Paraphilic Interest Questions

Paraphilic Interest	Original Question	CVI-I Value	Final Question (Modifications underlined)
Voyeuristic	Have you been sexually aroused (“turned on”) from the idea or fantasy of observing a person who is not aware that he/she is being observed, who is naked, in the process of disrobing, or engaging in sexual activity?	.91*	Have you been sexually aroused (“turned on”) from the idea, fantasy, or act of observing a nonconsenting person who is not aware that he/she is being observed, who is naked, in the process of disrobing, or engaging in sexual activity?
Exhibitionistic	Have you been sexually aroused (“turned on”) from the idea or fantasy of exposing your genitals (“private parts”) to a person who has not consented (agreed) to it?	1.0*	Have you been sexually aroused (“turned on”) from the idea, fantasy, or act of exposing your genitals (“private parts”) to a person who has not consented (agreed) to it?
Frotteuristic	Have you been sexually aroused (“turned on”) from the idea or fantasy of touching or rubbing against a person who has not consented (agreed) to it?	.91*	Have you been sexually aroused (“turned on”) from the idea, fantasy, or act of touching or rubbing against a person who has not consented (agreed) to it?
Sexual masochism	Have you been sexually aroused (“turned on”) from the idea or fantasy of being humiliated, beaten, bound, or otherwise made to suffer?	.91*	Have you been sexually aroused (“turned on”) from the idea, fantasy, or act of being humiliated, beaten, bound, or otherwise made to suffer?
Sexual sadism	Have you been sexually aroused (“turned on”) from the idea or fantasy of physical or psychological suffering of another person?	.91*	Have you been sexually aroused (“turned on”) from the idea, fantasy, or act of physical, psychological, or emotional pain and/or suffering of another person?
Pedophilic	Have you been sexually aroused (“turned on”) from the idea or fantasy of engaging in sexual activity with a prepubescent child (generally age 13 years or younger)?	1.0*	Have you been sexually aroused (“turned on”) from the idea, fantasy, or act of engaging in sexual activity with a prepubescent child (generally age 13 years or younger)?
Fetishistic	Have you been sexually aroused (“turned on”) from the idea or fantasy of nonliving objects (such as rubber, underwear or clothing, or shoes; not including sex toys or cross-dressing) or a part of the body that is not a genital (such as feet, elbows, or hair)?	.91*	Have you been sexually aroused (“turned on”) from the idea, fantasy, or act of the use of nonliving objects (such as rubber, underwear or clothing, or shoes; not including sex toys or cross-dressing) or a part of the body that is not a genital (such as feet, elbows, or hair)?
Transvestic	Have you been sexually aroused (“turned on”) from the idea or fantasy of cross-dressing (wearing clothes of the opposite sex)?	.91*	Have you been sexually aroused (“turned on”) from the idea, fantasy, or act of cross-dressing (wearing clothes of the opposite sex)?

*Indicates a CVI-I value that exceeds the recommended cutoff of .78.

Three questions were included to evaluate Criterion A of the paraphilic disorders criteria (duration, recurrence, and intensity). See Table 5 for the prompts the experts responded to regarding Criterion A.

Table 5.

PIDS Criterion A Questions.

Criterion A	Original Question	CVI-I Value	Final Question (Modifications underlined)
Duration	How relevant is this item in assessing whether paraphilic interests have occurred over a period of at least 6 months? “Have you experienced these sexual interests for longer than the past 6 months?”	.73	Have you experienced these sexual interests for at least the past 6 months? Yes, No, Prefer Not to Answer
Recurrence	How many instances (at minimum) of the paraphilic interest must occur in order for the paraphilic interests to be considered “recurrent”? Please enter a number.	N/A	In the past 6 months, how many times have you experienced this sexual interest? 1 time, 2 times, 3 times, 4 times, 5 times, 6 times, 7 times, 8 times, 9 times, 10 times, 11–20 (please specify the exact number), 21–50 times (please specify the exact number), 51–100 times (please specify the exact number), more than 100 times (please specify the exact number), Prefer not to Answer
Intensity	On a scale of 1–5, what is the minimum level of intensity you think is required for paraphilic interests to constitute a paraphilic disorder? 1 = low intensity, 2, 3 = moderate intensity, 4, 5 = high intensity	N/A	In the past 6 months, how intense has this sexual interest been? 1 = low intensity, 2, 3 = moderate intensity, 4, 5 = high intensity, Prefer Not to Answer

*Indicates a CVI-I value that exceeds the recommended cutoff of .78.

Moreover, experts were asked their opinion regarding what questions should be included to assist in determining Criterion B of the paraphilic disorders criteria. The experts were broadly asked if it was relevant that the person has experienced distress, impairment, or has acted on the interest when assessing for a paraphilic disorder (1 = not relevant, 2 = somewhat relevant, 3 = relevant, 4 = very relevant). Subsequently, they were asked to provide opinions on specific items that could assess for these constructs. See Table 6 for the prompts the experts responded to regarding Criterion B. Of note, experts were provided the opportunity to provide open-ended feedback after each of the aforementioned Criterion A and B questions.

Table 6.

PIDS Criterion B Questions.

Criterion B	Original Question	CVI-I Value	Final Question (Modifications underlined)
Distress	How relevant is it that the paraphilic interest has caused the individual distress when diagnosing a paraphilic disorder?	.64	N/A
	How relevant is this item in assessing whether paraphilic interests or behaviors cause distress? “How much does the fact that you are aroused (“turned on”) by this bother you or cause you distress?”	.73	How much has this sexual interest caused you distress (bothered you)? 1 = low distress, 2, 3 = moderate distress, 4, 5 = high distress, Prefer not to Answer
Impairment	How relevant is it that the paraphilic interest has caused the individual impairment when diagnosing a paraphilic disorder?	.86*	N/A
	How relevant is this item in assessing whether paraphilic interests or behaviors cause impairment?“Has the arousal or your acting on it gotten you into trouble with the law, gotten you in trouble or fired from a job, negatively affected a relationship, or interfered with your life because you spent so much time thinking about it?”	.91*	Has the sexual interest or your acting on it gotten you into trouble with the law, gotten you in trouble or fired from a job, negatively affected a relationship, or otherwise negatively interfered with your life because you spent so much time thinking about it?Yes, No, Prefer Not to Answer
Acting on the Interest	How relevant is it that the individual had acted on a paraphilic interest when diagnosing a paraphilic disorder?	.56	N/A
	How many times (minimum) do you think the person must have acted upon the paraphilic interest(s) (with a nonconsenting person) in order to constitute a paraphilic disorder?	N/A	How many times have you acted on this sexual interest (you engaged in a behavior related to the sexual interest)?Never, 1 time, 2 times, 3 times, 4 times, 5 times, 6 times, 7 times, 8 times, 9 times, 10 times, 11–20 (please specify the exact number), 21–50 times (please specify the exact number), 51–100 times (please specify the exact number), more than 100 times (please specify the exact number), Prefer not to AnswerWhat behavior(s) did you engage in? Select all that apply.Viewing pornography of the interest, Masturbating to pornography of the interest, Masturbating to the idea or fantasy of the interest, Engaging in the sexual interest with another person, Other (please specify)

*Indicates a CVI-I value that exceeds the recommended cutoff of .78

Lastly, we included one final open-ended question requesting experts’ additional feedback to the PIDS, “Please provide any additional comments about what you think are important/additional considerations when assessing paraphilic disorders (by self-report) below.”

Analytic Strategy

For the questions assessing relevance of items on the four-point Likert scale, analyses were conducted in accordance with the Content Validity Index (CVI) method (Lynn, 1986). This method uses expert feedback to establish content validity of items and has been used in social science research (e.g., social work, psychology, criminology; Haynes et al., 1995; Research Methods Knowledge Base, n.d.; Rubio et al., 2003; Winters et al., 2020). The CVI calculations examine the proportion of experts who identified the particular item as relevant (i.e., rated the item a 3 or 4 on the 4-point Likert scale). The CVI value for each item (CVI-I) is determined by dividing the number of experts who endorsed the item as relevant by the total number of experts in the sample (n = 22 in the present study). A cutoff of 0.78 or greater was used to assess inclusion of items (Shi et al., 2012), and identify questions in need of modifications. We also solicited open-ended feedback from experts throughout the content validation survey. Any suggestions for improvements by the experts were reviewed by the primary researchers and incorporated into modifications to the questionnaire, as described; the integration of qualitative feedback from select experts is consistent with measure development methodology (e.g., Harlacher, 2016; Rodrigues et al., 2017; Tsang et al., 2017).

Results and Discussion

Paraphilic Interests

There were eight items developed to assess for an individual’s paraphilic interests of the categories included in the DSM-5. Overall, all (100%) of the paraphilic interest items had CVI-Is that exceeded the recommended cutoff of .78 (CVI-Is ranged from .91 to 1.00; Median = .91) and thus, were considered relevant by the experts. See Table 4 for the CVI-I values for each paraphilic interest question.

Based on open-ended responses regarding recommendations to improve the items, we revised all paraphilic interest prompts to include “idea, fantasy, or act of” (rather than just “idea or fantasy”). Moreover, there were minor wording changes to voyeuristic (i.e., adding “nonconsenting”), sexual sadism (i.e., adding “emotional pain”), and fetishistic (i.e., adding “the use of”). See Table 4 for the final paraphilic interest questions for the PIDS, with relevant changes underlined. These changes were deemed by the primary researchers to be in line with terminology of the DSM-5 and would improve a respondent’s understanding of the items.

Criterion A

The experts assessed the validity of three potential questions related to the 6-month duration, recurrence, and intensity of the paraphilic interest (Criterion A of the DSM-5 diagnostic criteria). Regarding duration, the CVI-I for the question, “Have you experienced these sexual interests for longer than the past 6 months?” was .73, which is below the cutoff. Based on recommendations from open-ended responses, experts suggested a minor wording change (i.e., “at least” the past 6 months) to the original prompt, which would be more consistent with the DSM-5 language. To assess recurrence, we asked experts how many instances (at minimum) of the paraphilic interest must occur in order for the paraphilic interests to be considered “recurrent.” The responses ranged significantly on this item (range = 1–100; mode = 2). Thus, we decided to include a question that would encompass this wide range, with recurrence being defined as occurring two or more times during the 6-month period (based on the mode). The experts indicated their suggested minimum level of intensity required for paraphilic interests; the vast majority of the experts (n = 19, 86.36%) believed a rating of 3, 4, or 5 on that scale would constitute the minimum intensity required. This item was retained for the final scale and the cutoff of 3 will be used to indicate the paraphilic interests that were considered intense. See Table 5 final Criterion A questions for the PIDS, with relevant changes underlined.

Criterion B

We asked experts questions regarding the relevance of DSM-5 Criterion B qualifiers (distress, impairment, and having acted on the interest). The CVI-I relevance score of the individual experiencing distress as a result of the interest on diagnosing a paraphilic disorder was below the cutoff (CVI-I = .59). Namely, experts reported in open-ended responses that some individuals are not distressed by the interest. Nonetheless, we retained a question related to distress using a Likert-scale item, which was designed to be consistent with the formatting of the intensity item outlined above, given that distress is explicitly indicated in the DSM-5 criteria. Experts did, however, deem that the paraphilic interest causing impairment was relevant to a diagnosis of a paraphilic disorder (CVI-I = .86). They also indicated that the proposed question to assess impairment was relevant (CVI-I = .91), although we slightly modified the wording of the question to reflect recommendations from the experts (i.e., including “otherwise negatively” interfered with your life). The CVI-I for the relevance of the individual acting on the interest on diagnosing a paraphilic disorder fell below the cutoff for relevance (CVI-I = .59). The decision was made to retain a question related to acting on the interest, as this qualifier is included in the DSM-5 Criterion B. We used open-ended feedback to modify the proposed item, which revealed two themes: (1) experts wanted to clarify that a person can have a paraphilic disorder and not have acted on it; and (2) the term “acted on it” can refer to a range of actions (e.g., watching pornography or masturbation related to the interest). Therefore, we developed an item to clarify these points and more broadly assess the number of times a person has acted on the interest, with a follow-up regarding how they acted on the interest. See Table 6 for the final Criterion B questions for the PIDS, with relevant changes underlined.

Additional Recommendations

Experts were given the opportunity to provide additional feedback about the PIDS. The open-ended responses were reviewed, which revealed valuable suggestions to assess whether the individual’s endorsed interest was their preference or primary sexual interest. As such, we included the question, “Is this your preferred or primary sexual interest?” (Yes, No, Prefer not to answer) if the respondent endorsed a paraphilic interest.

Moreover, the experts suggested we include questions about paraphilic interests across the lifespan (rather than only the past 6 months outlined in the Criterion A of the DSM-5). Therefore, we included new questions to target this construct based on experts’ recommendations. If an individual endorsed having the paraphilic interest, “At what age did you first experience this sexual interest? Please enter a specific number.” And “What is the longest period of time you have experienced these sexual interests?” (0–5 months, 6–11 months, 1–2 years, 2–5 years, more than 5 years). Subsequently, for all of the Criterion A and B questions, we will ask the individual to complete those for the past 6 months and, if they endorsed having a previous period of at least 6 months with that interest, they would complete the questions for that period of time as well. See Appendix A for the final version of the PIDS.

Study 2: Pilot Data

Method

Participants and Procedure

Before finalizing a measure, it is recommended the measure is piloted on a small sample of respondents (approximately 30–100; Perneger et al., 2015; Ruel et al., 2016). The pilot data for the newly developed PIDS was collected through Prolific, an online platform used by academic researchers, which allows individuals to complete online research studies in exchange for monetary compensation. A sample of 100 adults^3,4, aged 18 or over, who reside in the United States (U.S.) and speak/write in English completed a 30-minute online survey. Participants received $4.00USD for their participation, an amount that is consistent with federal employment rates (United States Department of Labor, 2020) and has been shown to maximize valid data (Horton & Chilton, 2010). Participants reviewed the informed consent form and if they agreed to participate, they responded to demographic questions (age, sex, race/ethnicity, sexual orientation, educational level, employment status) and completed the PIDS. Following participation, they were thanked, provided a debriefing form, and awarded compensation.

Participants included 56 (56.0%) males and 44 (44.0%) females who resided in 33 different U.S. states. Ages ranged from 18 to 70, with the average being 34 years (SD = 12). Regarding race/ethnicity, most participants were White (n = 75; 75.0%), along with 15 (15.0%) who identified as Asian, 5 (5.0%) as Latinx, 4 (4.0%) as Black, and 1 (1.0%) as mixed race. Most identified as heterosexual (n = 80; 80.0%), while 12 (12.0%) identified as bisexual, 4 (4.0%) as gay/lesbian, 3 (3.0%) as asexual, and 1 (1.0%) as pansexual. A range of educational backgrounds were represented, including graduated high school (n = 13; 13.0%), GED (n = 2; 2.0%), some college (n = 24; 24.0%), graduated college (n = 37; 37.0%), some graduate school (n = 1; 3.0%), and completed graduate school (n = 23; 23.0%). In terms of employment, 63 (63.0%) worked full-time, 8 (8.0%) part-time, 12 (12.0%) were unemployed, 9 (9.0%) were students, 2 (2.0%) were retired, and 1 (1.0%) was self-employed; 5 (5.0%) declined to respond.

Results and Discussion

There are numerous ways that feasibility of a measure can be evaluated (Bowen et al., 2009). We utilized our pilot data to assess the most important areas of feasibility as it relates to the PIDS. Specifically, we assessed feasibility in terms of implementation (i.e., ability to administer and gather data from a sample of the general population) and limited-efficacy testing (i.e., whether the measure obtained the designed outcome; Bowen et al., 2009; Kasturi et al., 2018; Ruel et al., 2016; Russell et al., 2018; Winters & Jeglic, 2021). First, the PIDS was easily implemented in an online, self-report survey format, as all 100 participants responded to the items on the measure and the appropriate skip logic for questions was administered. There were very few “Prefer not to Answer” responses throughout. For example, for the initial inquiry regarding each of the eight interests, the number of Prefer not to Answer responses was between 0 (0.0%) and 2 (2.0%; See Table 7). None of the respondents exited the survey before completing the PIDS in its entirety. Additionally, all 100 participants accurately answered two attention check questions (immediately before and after the PIDS), suggesting they attended to the content of the survey.

Table 7.

Prevalence Rates from PIDS Pilot Data.

Interests		Yes	No	Prefer not to Answer
Interests		n (%)	n (%)	n (%)
Voyeuristic	Total	37 (37.0)	61 (61.0)	2 (2.0)
	Past 6 months*	14 (37.8)	—	—
	6 months in lifetime*	23 (62.2)	—	—
Exhibitionistic	Total	7 (7.0)	93 (93.0)	0 (0.0)
	Past 6 months*	6 (85.7)	—	—
	6 months in lifetime*	4 (57.1)	—	—
Frotteuristic	Total	7 (7.0)	92 (92.0)	1 (1.0)
	Past 6 months*	3 (42.9)	—	—
	6 months in lifetime*	4 (57.1)	—	—
Sexual masochism	Total	19 (19.0)	80 (80.0)	1 (1.0)
	Past 6 months*	8 (42.1)	—	—
	6 months in lifetime*	10 (52.6)	—	—
Sexual sadism	Total	2 (2.0)	97 (97.0)	1 (1.0)
	Past 6 months*	2 (100.0)	—	—
	6 months in lifetime*	2 (100.0)	—	—
Pedophilic	Total	1 (1.0)	99 (99.0)	0 (0.0)
	Past 6 months*	1 (100.0)	—	—
	6 months in lifetime*	1 (100.0)	—	—
Fetishistic	Total	15 (15.0)	85 (85.0)	0 (0.0)
	Past 6 months*	10 (66.7)	—	—
	6 months in lifetime*	10 (66.7)	—	—
Transvestic	Total	4 (4.0)	96 (96.0)	0 (0.0)
	Past 6 months*	2 (50.0)	—	—
	6 months in lifetime*	3 (75.0)	—	—

*Percentages for past 6 months and 6 months in lifetime are based on the number of participants who endorsed having that interest at some point in their lifetime.

Secondly, we conducted limited-efficacy testing of the PIDS by examining content of the responses for the piloted data to ensure: (a) the level of endorsement was relatively consistent with prior studies, and (b) there was some variability in responding for each question. First, the level of endorsement of the paraphilic interests were relatively consistent with prior literature (see Table 2), with percentages ranging from 1–37% for a lifetime experience of each paraphilic interest, with lower percentages for each of the two specified time periods (i.e., at least the past 6 months; a period of 6 months or more during their lifetime). For example, prior studies on voyeuristic disorder suggest the frequency in non-clinical samples ranges between 26.0%–52.0% (Bártová et al., 2021; Dawson et al., 2016; Joyal & Carpentier, 2017); our pilot data showed 37% of the sample endorsed voyeuristic interests, which falls within this range. See Table 7 for the prevalence rates for each paraphilic interest, and the endorsement of these interests during the two specified time periods. Second, we reviewed the responses for all PIDS questions, which showed appropriate variability across responses. That is, there were no ceiling or floor effects for items, unless it was expected an item may skew one direction based on theoretical explanations (e.g., a very low endorsement of acting on pedophilic interests). We included an example of responses of one category, voyeuristic interests, to demonstrate the variability in responses for each individual PIDS item (See Figure 2). Overall, based on the pilot data, the PIDS appears to be able to be feasibility implemented, and there was evidence for its limited-efficacy.

Figure 2.

oyeuristic interests PIDS pilot data. PA = Prefer not to Answer. *Percentage based on number of participants who endorsed voyeuristic interests. **Percentage based on the number who endorsed having the interest during that particular time span. ***Percentages based on the number of participants who endorsed acting on the interest.

General Discussion

Past studies on paraphilic interests and behaviors have methodological limitations, especially due to the fact the measures used in those studies neglected to thoroughly and adequately address the DSM-5 paraphilic disorder diagnostic criteria and categories. There remains a need for a comprehensive self-report assessment of paraphilic interests and disorders based on the diagnostic language in the DSM-5. The present study aimed to develop, establish content validity, and pilot a self-report measure of DSM-5 paraphilic interests and disorders, the Paraphilic Interests and Disorders Scale (PIDS). In Study 1, we established content validity for the PIDS using feedback from 22 experts in the field. In Study 2, we piloted the new measure on a sample of 100 respondents, which provided support for the measure’s feasibility in terms of implementation and its limited-efficacy. Overall, the use of opinions from both researchers and clinicians in the field promotes a more nuanced understanding of the assessment of paraphilic interests and disorders, and the initial pilot data was promising regarding the feasibility of the PIDS. Ultimately, with further empirical support for its validity and other psychometric properties, we hope that the proposed scale will facilitate more accurate and consistent findings in research and, subsequently, inform clinical practice.

Given the controversy surrounding the measurement of paraphilic interests and disorders, we felt that it was important to first explain the process of developing the PIDS, along with a thorough description of how content validity and feasibility were established for this newly proposed online, self-report assessment of paraphilic interests and behaviors. Now that measure has been developed and pilot tested, the next phase of this research will involve further establishing the psychometric properties of the PIDS (e.g., construct validity through correlations with other measures of sexual interests) and administering the PIDS via an anonymous online survey to a large sample of community members in the U.S. We expect these results will provide further support for the use of the PIDS, as well as help shed light on the much-needed prevalence rates of the DSM-5 paraphilic interests and disorders within the general population. There remains significant stigma in society regarding paraphilic interests, such as engaging in sadistic or masochistic behaviors, which in many cases are consensual in nature (Dunkley & Brotto, 2018). It is important to empirically examine whether these paraphilic interests are indeed infrequent, or whether they may be more common than previously assumed (Fedoroff et al., 2013).

Paraphilic Interests Versus Behaviors

Importantly, the data obtained from our large population-based study with the PIDS will also facilitate a more nuanced examination of these DSM-5 constructs. Many prior prevalence studies have failed to distinguish between individuals with paraphilic interests and those who have actually acted on them (i.e., some may endorse the interest, but have not engaged in behaviors related to those interests). Of those studies that have (e.g., Joyal & Carpentier, 2017), findings suggest that the interests are more frequently endorsed than having actually engaged in the behavior. It is important to understand this distinction given that paraphilic behaviors, except for transvestic and fetishism, have been found to consistently and independently be associated with sexually coercive behavior (Baur et al., 2016). Baur et al. (2016) theorized that certain behaviors (e.g., frequent masturbation involving the paraphilic fantasies; exhibitionistic and voyeuristic behaviors that involve nonconsenting others but are non-contact) may lead to more aggressive sexual behaviors (i.e., contact offenses, such as rape).

Paraphilic Interests Versus Paraphilic Disorders

Moreover, studies have failed to examine how many individuals would likely classify as having a paraphilic disorder, compared to how many endorse the paraphilic interest (i.e., some may endorse the interest, but have not experienced distress, impairment, or acted on it with a nonconsenting person). As one prior study found, 62.4% of men in the general population in Germany reported a paraphilia-associated sexual arousal pattern, but only 1.7% of them reported the interest has caused them distress (Ahlers et al., 2011). If the interest is not resulting in distress, impairment, or nonconsensual behaviors, then the concern regarding this individual being risky or deviant may not be warranted (Lehmann et al., 2020). Furthermore, one interesting finding from our content validation study was that experts did not deem it relevant that an individual experiences distress or has acted on the paraphilic interest when diagnosing a paraphilic disorder. It may be that the experts interpreted these relevance items as the distress or behaviors must be present before diagnosing a disorder. However, the DSM-5 indicates these factors need not all be present, by stating, “The individual has acted on these sexual urges with a nonconsenting person, or the sexual urges or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.” (APA, 2013, p. 687). Therefore, it will be interesting to investigate in future PIDS studies the number of people who endorse: (a) distress, (b) impairment, and/or (c) acting on the behavior with a nonconsenting individual, which no study has explored to date.

Further Areas of Study

It should also be noted that data obtained using the PIDS will open up a range of research questions that have been largely neglected in the literature and DSM-5 description of paraphilic disorders. For example, this data would shed light on the prevalence rates across the lifespan compared to recent/current endorsement, which was deemed an important distinction according to the experts who participated in the content validation study. There are conflicting views regarding whether paraphilic interests are stable or fluid throughout the lifetime (Cantor, 2018; Cantor & Fedoroff, 2018; Kleinplatz & Diamond, 2014). The PIDS may be helpful in providing additional evidence regarding whether these interests, behaviors, or distress/impairments may be fluid and change over time or remain relatively stable and fixed by providing both current and lifetime prevalence information. The data may also permit the investigation of the relationship between paraphilic interests and/or behaviors and the onset and maintenance of sexual offending behaviors, as prior research has shown an association between these constructs and sexually inappropriate behavior (Baur et al., 2016; Mann et al., 2010). Additionally, there is a dearth of literature regarding demographic differences, such as the differences in prevalence rates across sexes, sexual orientations, races/ethnicities, and ages. These demographic characteristics are provided in the DSM-5 for most disorders, but are largely lacking for the paraphilic disorders (APA, 2013). Lastly, the data will allow for a more in-depth exploration of co-morbidities, including whether individuals endorsing paraphilic interests and disorders also report substance use, mental illness, personality disorders, or cognitive limitations. It is suggested that paraphilic disorders are highly comorbid with depressive disorders, bipolar disorder, anxiety, substance use disorders, hypersexuality, antisocial personality disorder, and other paraphilic disorders, (APA, 2013); however, it is unclear whether there is indeed substantial empirical evidence to support this notion.

Limitations

There are a few notable limitations with the present study. First, for Study 1 (content validation) we had a relatively low response rate (14.1%) from research experts. It is unclear the reason for this response rate, whether it be a result of the individual not receiving the invitation to participate (e.g., the email may have been sent to an old email address or a junk folder) or they declined to participate in the study (e.g., time required to complete the survey; they did not consider themselves to be an expert). While there is not necessarily a required response rate when conducting content validation study, a larger response rate would provide more support for the generalizability of the experts’ opinions. Nonetheless, the number of experts required for a content validation study is at least 7 (DeVon et al., 2007; Polit & Hungler, 1999), and previous studies involving experts range from 2 to over 20 (Olson, 2010), so our expert sample comprising both the researchers and clinicians is in the top end of this range. Also, it should be noted that most experts in the sample had clinical experience, which may impact the perceptions and opinions regarding the assessment of paraphilic interests; however, we believe we were able to obtain a sample that is inclusive of various perspectives. That is, when experts were asked what experience(s) best describe their work with paraphilic interests/disorders, responses also included theoretical publications (59%), empirical research (36%), and other relevant experiences (32%; e.g., teaching, training).

Furthermore, one component of the revision process in Study 1 involved our integration of qualitative feedback from experts’ open-ended comments, in order to gather a full range of recommendations that could not be obtained solely from quantitative data (i.e., CVIs). Given that we made judgments on which recommendations were appropriate to integrate, there was some subjectivity to this process. However, we believe this qualitative feedback further strengthened the measure and the use of these types of recommendations by experts is consistent with prior methodologies (e.g., Harlacher, 2016; Rodrigues et al., 2017; Tsang et al., 2017).

Another limitation of the PIDS itself is that it is a self-report measure of potentially sensitive and stigmatizing topics. Thus, the measure (as with any measure containing sensitive content) may be subject to socially desirable responding, as paraphilic interests may cause the person shame or embarrassment and thus, they may be reluctant to report (especially in the case the behavior may be considered illegal). However, research has shown that when online self-report surveys were compared to telephone surveys, there were higher reporting rates of paraphilic interests and behaviors (Joyal & Carpentier, 2017); as such, we believe this method to be superior to other, more personal, administration procedures. It must be noted that we do not support this measure being used to formally establish a diagnosis of disorder based solely on self-report; as with any disorder in the DSM-5, a more thorough clinical evaluation would be needed to qualitatively understand the individual’s experience with the interests and associated consequences before formally diagnosing a paraphilic disorder.

The proposed PIDS was designed based on the criteria for the DSM-5 to most closely reflect the exact language proposed in this manual. However, the ICD-11 is another diagnostic manual widely used across countries. Thus, while the proposed PIDS does not directly map on to this criteria, future research could aim to develop or expand the PIDS to also address the specific diagnostic criteria for the ICD-11. Also related to the content of the PIDS, the measure uses ordinal scales for several questions (e.g., intensity, distress). This is necessary to quantify these constructs in the context of a self-report scale that will be used on a large sample, but there are limitations of using this type of measurement (Bouchard et al., 2017).

Last, while the present research established content validity for the measure, as well as evidence of feasibility, there are additional psychometric properties that need to be examined to further support the use of the PIDS in research and practice. There are additional areas of feasibility that could be examined, such as acceptability (e.g., participants’ reactions to the measure) or adaptation (e.g., implementation in a different format, such as telephone or in-person interviews; Bowen et al., 2009). We were unable to assess the length of time it takes to complete the PIDS itself, as the respondents answered other questions (e.g., demographics) that are not a part of the measure during the survey; an area of future investigation could include the length of administration required for the PIDS. Further, convergent and discriminant validity could be examined through administration of the PIDS alongside prior measures of sexual arousal, and test–retest reliability could be explored through two administrations of the PIDS to the same participants. We foresee these steps being conducted in future research projects after the PIDS is tested on samples of participants from the community.

Conclusion

Taken together, the development and content validation of the PIDS by experts can open the door to fruitful research endeavors, especially given the promising feasibility findings from the pilot data. All of the aforementioned research questions have notable implications for clinical practice, as empirical data is needed to better assess, diagnose, and treat paraphilic interests or disorders—both in community, clinical, and forensic settings. For example, should paraphilic interests and disorders be more common than previously understood, it would raise clinicians’ awareness in the non-forensic settings to inquire about these disorders when assessing clients. During treatment, a clinician would be better able to target problematic sexual interests, such as the negative consequences for the individual, the extent to which these interests are abnormal (or not), and whether these tend to persist over a lifetime or are malleable.

Should validity and reliability be established for the use of the PIDS in forensic settings, this may help inform risk assessment practices and recommendations for risk management. Paraphilic interests and disorders can result in the commission of a sexual offense if the urges are acted upon with a nonconsenting adult or a minor. Indeed, it has been shown that paraphilic interests are related to increased risk for sexual offending (Baur et al., 2016); paraphilic behaviors, except for transvestic and fetishism, were consistently and independently associated with sexually coercive behavior. There is some emerging evidence that individuals that engage in non-contact paraphilic behaviors will go on to commit contact sexual offenses (Kaylor & Jeglic, 2019). There is also evidence that more intense offense-related sexual interests are associated with sexual recidivism (Mann et al., 2010). Despite the high potential for law-breaking behavior among various paraphilic disorders described in the DSM-5, few categories report prevalence rates for forensic populations (APA, 2013). As such, with further psychometric support, the PIDS could be used as a measure for forensic populations in the future in order to gain a better understanding of prevalence, as well as comorbidity, and help inform risk assessment and management decisions. However, not all individuals who have paraphilic interests will engage in sexual offending and not all sexual offenders have these interests; this is an important distinction for forensic evaluators to understand, which is only possible if we have a better understanding of prevalence rates for non-offending individuals.

In conclusion, we propose the content validated PIDS might serve as a measure of DSM-5 paraphilic interests and disorders in the general population. This will help facilitate future research examining topics that have thus far been understudied. It is expected that the empirical data garnered from the use of the PIDS in studies will provide beneficial information for clinicians and researchers alike to better understand how these interests may subsequently result in a diagnosable disorder and/or commission of a sexual offense.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The pilot data was funded by Fairleigh Dickinson University.

Data Availability

The authors take responsibility for the integrity of the data and the accuracy of the data analyses.

ORCID iDs

Georgia M. Winters

Elizabeth L. Jeglic

Supplementary Material

Supplementary material for this article is available online.

Notes

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