LETTERS

Editor:

I would like to congratulate Allen Frances, MD, and Richard Wollert, PhD, for their timely and succinct commentary on sexual sadism published in the September 2012 issue.¹ Their review of the history of the Diagnostic and Statistical Manual of Mental Diseases (DSM) diagnostic criteria for sexual sadism is an important reminder to all clinicians tasked with accurately diagnosing paraphilias and conducting risk assessments.

For the past 20 years, as a practicing forensic and clinical psychologist I have evaluated thousands of individuals and testified as an expert hundreds of times, including evaluating men as to whether they met the criteria for sexually violent predator and testifying in sexually violent predator civil commitment trials. I share Drs. Frances' and Wollert's concerns that evaluators already prone to overreliance on the diagnosis of paraphilia NOS, nonconsent, may begin to diagnose sexual sadism more readily when faced with evaluating an individual with a criminal history that includes the violent crime of rape.

In cases that I have been involved with, I have already personally witnessed the recent evolution of the use of paraphilia NOS, nonconsent, from last-minute, pretrial changes by an evaluator to assigning a diagnosis of sexual sadism. Unfortunately, I have also witnessed a recent increase in the meaningless use of a rule-out diagnosis of sexual sadism, added to written reports by evaluators who have diagnosed paraphilia NOS, nonconsent. Most troubling, however, are addendums I have read in the cases in which I have been involved, submitted by evaluators sometime between the actual evaluation of the individual and the trial date, suddenly attaching a scoring of the Severe Sexual Sadism Scale¹ when sexual sadism had not even been considered in the evaluation.

In the absence of civil commitment laws, would the prevalence rates of this documentarily rare paraphilia be on the rise? Of course not. There is no scientific evidence that crimes of rape are increasingly motivated by strongly embedded intrapsychic sadistic fantasies. Yet, I fear that we may see this phenomenon increasingly reported despite Drs. Frances' and Wollert's well-reasoned recommendations to provide sufficient evidence for the diagnosis.